EFTA00311381.pdf

lath tail INUIl With iu Mercedes-Benz Mercedes-Benz Premier Prepaid Maintenance Application for - Coverage DARREN K INDYKE PLLC 56113 MERCEDES-BENZ MANHATTAN, INC. Purchaser Last Name 575 LEXINGTON AVE FL 4 Frst Dealer Code Dealer Name MERCEDES-BENZ MANHATTAN, INC. Address NEW YORK NY 100226146 D/B/A NEW YORK NY City State Zip one Dealer City State Llenholder Name Address ML350W4 City ML350W4/2015 State Zip Phone Vehicle Identification Number New Vehicle Retail Date Model Model Year Original New Vehicle In-Service/Warranty Start Date: Month Day Year Current Mileage 12 Agreement Type/Term' Premier40K NPPMS- Purchase Price S 1,825 CO 4YR Agree nd Date: (rai  Cusco nature Day Year + Sales Tax S 161.97 = Total Purchase Price $ 1,986.97 05/15/2015 THERESA INGANNAMORTE 05/15/2015 Dale Dealer Representative Signature Rep Name Date V This checkmark indicates you are providing the equivalent of your signature and indicating your intent to enter into this agreement upon acceptance. EFTA00311381