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(!) IMPORTANT: Photocopy your entire submission for your records. You may be required to mail or fax these photocopies.

*First Name *Last Name

*Address

*City *State *Zip Code

*Email Phone

Customer Information Section

*Repair Order Number

The 7 or 8 digit GM Parts Number(s) found on your Repair Order must be included on this form.

*Dealership Name *Dealer Zip Code *Date of Purchase (MM/DD/YY)

*Vehicle VIN Number

$200 GM Certified Service Dealer Service Lane Rebate1 Offer Valid: 10/01/2020 - 12/31/2020

If the Engine, Transmission or Transfer Case Part Number(s) is not included on your Repair Order, contact your GM dealer to obtain the required information.

If you have not received your Certified Service Rebate Visa® Prepaid Card within 8 weeks after the postmark date of your qualified submission, or if you have questions about your submission, call (866) 713-7284 weekdays, 8am to 4:15pm Central Time.

Offer valid for customers who make the purchase at a participating Chevrolet, Buick, GMC or Cadillac Dealer in the United States. In order to receive the mail-in rebate debit card, qualifying purchases must satisfy the rebate requirements as outlined on this rebate application. Failure to meet the mail-in rebate requirements will disqualify your rebate. This offer is available to retail customers with mailing addresses in the United States. This offer is not valid on products being replaced under warranty. Fleet and commercial customers and GM Company Vehicles are not eligible for this offer. Internal dealership sales are not eligible for this offer. This offer cannot be combined with other General Motors offers. Limit one (1) rebate per service performed per service date and vehicle and cannot be assigned or transferred. This offer is void where taxed, restricted or prohibited by law. General Motors and their partners are not responsible for lost, late, damaged, illegible, misdirected or postage-due submissions. Any excessive submissions, misrepresentation or fraudulent information disqualifies the rebate and may give rise to criminal or civil prosecution. All rebates shall be governed by applicable state and federal laws. All terms, conditions and rules of this program are subject to change. All submitted materials become property of General Motors and will not be returned. General Motors reserves the right to substitute a check of equal value in lieu of a Visa prepaid card at its discretion. Card is issued by MetaBank®, N.A., Member FDIC, pursuant to a license from Visa U.S.A. Inc. No cash access or recurring payments. Can be used everywhere Visa debit cards are accepted. Card valid for up to 6 months; unused funds will forfeit after the valid through date. Card terms and conditions apply. Please allow up to 6 to 8 weeks for delivery of the rebate.

To receive your rebate, follow these conditions of acceptance:

Purchase an eligible GM Genuine Engine, Transmission or Transfer Case for a Chevrolet, Cadillac, Buick, GMC, Pontiac, Oldsmobile, Saturn or Hummer (excludes Saab) vehicle and have them installed at a participating Chevrolet, Buick, GMC or Cadillac Dealer between October 1, 2020 and December 31, 2020.

REQUIREMENT: All parts MUST be GM Genuine or ACDelco parts (e.g. including fluids, engine oil, transmission fluid, engine mounts, transmission mounts, spark plugs, radiator hoses, fuel filters, antifreeze, oil filter, etc.) to be eligible for this offer. Aftermarket parts and/or fluids cannot be utilized.

Complete all information requested on this form accurately and legibly. Make a clean, legible copy of your Repair Order including the Dealer and circle the purchase(s).

To receive your rebate faster, submit online: Using a computer, tablet or mobile phone, go to www.mycertifiedservicerebates.com and follow the instructions. You will be required to upload a copy of your Repair Order. To submit via mail: Complete all information requested on this form accurately and legibly. Mail this form, along with a copy of your Repair Order to the address listed to the right. Please keep copies of your Repair Order until your rebate is approved. Submission must be postmarked by January 31, 2021.

By providing your contact information below, you consent that GM and/or a GM dealer may contact you with any GM offers and GM product information. For more information on the GM Privacy Statement please visit our website http://www.gm.com/privacy-statement.

EXCLUDES: Saab, Chevrolet Medium/Heavy Duty Trucks, GMC Medium and Heavy Duty Truck transmissions. Excludes Chevrolet Performance engines and transmissions

Mail to:Certified Service Dealer Service Rebate Offer Number 2020053P.O. Box 341835 Bartlett, TN 38134

*GM Part Number of Engine Purchased and Installed (Part Number is either 7 or 8 digits) ___ ___ ___ ___ ___ ___ ___ ___*GM Part Number of Transmission Purchased and Installed (Part Number is either 7 or 8 digits) ___ ___ ___ ___ ___ ___ ___ ___

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■Engine

Transmission

OR

OR

Transfer Case ■*GM Part Number of Transfer Case Purchased and Installed(Part Number is either 7 or 8 digits) ___ ___ ___ ___ ___ ___ ___ ___

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What Brand of Vehicle do you drive? Chevrolet Buick GMC Cadillac Other

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