Gm Mobility Form – Fill Out and Use This PDF

1.OBTAIN ADAPTIVE EQUIPMENT PURCHASE RECEIPT

2.VEHICLE PURCHASER INFORMATION — PLEASE USE BLUE INK AND COMPLETE ALL INFORMATION

After your vehicle adaptations are completed, obtain an item- ized paid invoice from the licensed equipment installer(s). The invoice must include the following:

Preprinted installer company name, address and phone number

Your name, address and phone number

Vehicle Identification Number (VIN)

Description of the adaptive equipment installed on vehicle

Date of adaptation (sale)

Itemized cost of parts AND labor (listed separately)

Proof of payment for the adaptation (copy of credit card receipt, canceled check or paid invoice with $0 balance)

PURCHASER INFORMATION

Mr.  Ms. _______________________________________

LASTFIRSTM.I.

Mailing Address ____________________________________

City _______________________________________________

State/ZIP ______________________/____________________

Home Phone (________)______________________________

Work Phone (________)______________________________

Email Address ______________________________________

Vehicle sold/traded in:

Vehicle Make ____________ Model____________ Year______

First-time GM Mobility Reimbursement Program user?  Yes  No

Primary personal mobility aid used:  Wheelchair

Scooter  Cane/Walker/Crutches  Other  None

For information on GM’s privacy statement, please visit gm.com/privacy or call 1-866-MY-PRIVACY (1-866-697-7482).

VEHICLE/EQUIPMENT INFORMATION

Vehicle ID No. (VIN) __________________________________

Delivery Date ______/______/______

Vehicle Make __________ Model ___________ Year_______

Check appropriate box:

 Retail Sale  Retail Lease  Commercial Sale

DESCRIPTION OF ADAPTIVE EQUIPMENT INSTALLED

_____________________________________________________

Date of Adaptation ______/______/_______

Total Cost of Adaptation $ _______________

Reimbursement Amount Requested $__________________

($1,000 maximum*)

NOTE:Aletterfromyourphysiciandescribingthelimitationsofyourdisability is required for assist steps/running boards,assist handles,electric parking brake,inverter,pedal extenders andremote liftgate opener.

*$1,200maximumforChevyExpressandGMCSavanavans(andcutaways).

DEALER INFORMATION

Dealer Name: __________________________________

Dealer BAC Code: ________________________________

Phone: ______________________________________

Fax: ________________________________________

VALIDATION (REQUIRED)

I have examined the eligible vehicle identified on this application, and it is equipped with the adaptive mobility equipment described on the attached

invoice(s).

________________________________________

GM Dealer Representative Signature

________________________________________

Print Name

________________________________________

Equipment Inspection Date

Send reimbursement payment to (check one):

 The GM dealer above  The vehicle purchaser

If the dealer is requesting payment, one of the following documents must accompany the application:

•Customer Incentive Acknowledgment and/or Assignment Form

•Copy of dealer check(s) issued to equipment installer(s)

•Copy of sales contract reflecting mobility incentive deduction

5. VERIFY YOUR APPLICATION IS COMPLETE

Gather your reimbursement application and all necessary attachments. Incomplete applications can delay claims processing. Make sure you have the following:

ORIGINAL itemized invoice(s), including proof of payment

Letter of authorization from your lessor if this is a leased vehicle

If dealer is requesting payment, remember to provide ONE of the following:

Customer Incentive Acknowledgment and/or Assignment Form or copy of dealer check(s) issued to adaptive equipment installer(s) or copy of sales contract reflecting mobility incen- tive deduction

For reimbursement of assist handles, assist steps/running boards ($200 maximum), electric parking brake, pedal extenders, inverter, and remote liftgate opener($500maximum),provide signedletterfromphysician describing disability/limitation with physician’s name,license number, address,and phone number

ORIGINAL completed and signed reimbursement application

6.MAIL APPLICATION

Mail your application and all required attachments to:

GM MOBILITY PROGRAM HEADQUARTERS

P.O. BOX 5053

TROY, MI 48007

PLEASE KEEP A COPY OF THE APPLICATION AND ALL SUPPORTING DOCUMENTS FOR YOUR FILES.

This claim and any payment made under this claim are subject to the Official Program Rules and Guidelines that are in effect from 10/1/11 to 9/30/12 and have been made available to all authorized GM dealers. General Motors reserves the right to modify or terminate this program without notice.

SERVICE REQUEST NUMBER FOR INTERNAL USE ONLY

Eligible adaptive equipment for drivers and/or passengers >

Equipment must be:

•Permanently installed in the vehicle

•Installed for a driver or passenger with a permanent disability

•Purchased from and installed by a licensed equipment installer (see note below)

NOTE: For equipment eligibility information, call the GM MOBILITY assistance center at 1-800-323-9935. Except for OnStar TTY equipment and safety belt extenders, equipment available from General Motors (i.e., regular production options and GM Accessories) is not eligible for reimbursement. This includes, but is not limited to, assist steps/running boards.

Vehicles shown on this page and brochure cover have been altered or upfitted with equipment from independent suppliers. General Motors does not assume responsibility for the quality, safety or efficiency of aftermarket adaptive equipment or installation and cannot guarantee that such modifications comply with all applicable safety standards. Consumers should obtain complete information and references prior to purchasing such devices and having a vehicle adapted.

VEHICLE ENTRY		BRAKE/ACCELERATOR SYSTEMS
• Assist Handle1		• Brakes — Reduced Effort
• Assist Step/Running Board1,2		• Brake System — Emergency Backup
($200 maximum)		• Parking Brake — Push/Pull Control
• Ramp		• Parking Brake — Extension Lever
• Transfer Platform		• Parking Brake — Electric1
• Wheelchair and/or Scooter Lift		• Pedal Extenders1
		• Hand Controls
		• Servo-Assisted Hand Controls
		• Left-Foot Accelerator
<		>

3		M O B I L I T Y

O N S T A R T T Y E Q U I P M E N T

OnStar services are available for deaf, hard of hearing or speech-impaired subscribers through the OnStar TTY interface module. Available on select GM vehicles, this equipment enables most OnStar services to be delivered to the subscriber via TTY text messages in the vehicle. The equipment (shown below) is eligible for GM Mobility Reimbursement. For more information, visit gmmobility.com or call 1-800-833-9935.

GM MOBILITY PROGRAM FEATURING ONSTAR

HELPING YOU ACHIEVE BETTER MOBILITY > Customers who purchase/lease an eligible, new Chevrolet, Buick or GMC vehicle and have eligible adaptive mobility equipment1 installed or reinstalled on their new vehicle can receive a combination of financial assistance and the protection and convenience of OnStar2 through the GM Mobility Reimbursement Program.3

•First, get up to $1,0004 reimbursement ($1,200 on Chevy Express and GMC Savana) of the cost of any eligible adaptive equipment when installed (or reinstalled) on any eligible, purchased or leased 2011, 2012 and 2013 new Chevrolet, Buick or GMC vehicle delivered between 10/1/11 and 9/30/12.

•Second, customers who purchase eligible GM vehicles equipped with OnStar also qualify for

two extra years of standard OnStar service (Directions & Connections® Plan standard on 2012 GM vehicles).

—This offer is at no additional cost and is on top of the standard OnStar service included on new OnStar-equipped GM vehicles.

—OnStar is standard for 6 months on most 2011 and 2012 GM vehicles.

This Reimbursement Program guide and application are valid for eligible, new and unused 2011, 2012 and 2013 model year Chevrolet, Buick and GMC vehicles delivered between 10/1/11 and 9/30/12.

1 General Motors does not assume responsibility for the quality, safety or eficiency of aftermarket adaptive equipment or installation and cannot guarantee that such modiications comply with all applicable safety standards. Except for OnStar TTY equipment and safety belt extenders, equipment available from General Motors (i.e., regular production options and GM Accessories) is not eligible for reimbursement.This includes, but is not limited to, assist steps/running boards. Call the GM Mobility Assistance Center if you have questions about equipment eligibility. 2 Visit onstar.com for coverage map, details and system limitations. Services vary by model and conditions. OnStar acts as a link to existing emergency service providers. 3 These program guidelines have been made available to all authorized GM dealers.To use this offer on leased vehicles, lessor’s written approval must be obtained prior to adapting the vehicle. Most leet vehicles, with the exception of daily rentals, are compatible with the GM Mobility Reimbursement Program incentive. Used vehicles and vehicles obtained by GM dealers through auction are NOT eligible for the GM Mobility Reimbursement Program. General Motors reserves the right to modify or terminate this program without notice. 4 Limit $1,000 total reimbursement per eligible vehicle ($1,200 for Chevrolet Express and GMC Savana). Cadillac vehicles not eligible.

5		M O B I L I T Y

TAKING ADVANTAGE OF BOTH OFFERS IS AS EASY AS 1, 2, 3:

1.Buy or lease an eligible, new 2011–2013 Chevrolet, Buick or GMC vehicle equipped with OnStar

2.Purchase and install (or reinstall) eligible adaptive equipment

3.Apply for and receive

GM Mobility Reimbursement (see application page)

OnStar will credit your account for the two years of service after Mobility Reimbursement claim is processed.

To qualify for the Reimbursement Program, vehicle must be adapted and a claim must be submitted within 6 months of the date of purchase/lease. OnStar offer has no redeemable cash value and is nontransferable. OnStar offer excludes reimbursement for safety belt extenders. Other program rules apply. For offer details or questions about adaptive equipment or vehicle eligibility, visit your local dealer

or call the GM Mobility Assistance Center at 1-800-323-9935.

HOW CAN I BE SURE MY VEHICLE IS ELIGIBLE FOR THE PROGRAM? > For the GM Mobility Reimbursement Program, in effect until September 30, 2012, you must purchase or lease* an eligible, new and unused (not previously titled) 2011, 2012 or 2013 Chevrolet, Buick or GMC vehicle. To qualify for two extra years of standard OnStar service, vehicle must be an eligible 2011–2013 Chevrolet, Buick or GMC vehicle equipped with OnStar.† To confirm eligibility of

avehicle, you can call the GM Mobility Assistance Center at 1-800-323-9935. You will need your vehicle identification number (VIN). Confirmation of vehicle eligibility does not imply claim approval.

WHAT ADAPTIVE EQUIPMENT QUALIFIES FOR GM MOBILITY REIMBURSEMENT? >

See pages 4 and 5 for a complete list of eligible adaptive equipment. Except for OnStar TTY equipment and safety belt extenders, GM regular production options and GM Accessories are not eligible for GM Mobility reimbursement. This includes, but is not limited to, assist steps/running boards. Repairs and adjustments to equipment are also not eligible for reimbursement. Safety belt extenders are not eligible for OnStar offer.

IS USED ADAPTIVE EQUIPMENT ELIGIBLE? > Yes, provided it is on the list of eligible adaptive equipment and purchased from and installed by a licensed equipment installer. The cost to transfer equipment installed in your previous vehicle to your new, eligible vehicle is also reimbursable.

ARE ASSIST STEPS/RUNNING BOARDS ELIGIBLE FOR GM MOBILITY REIMBURSE-

MENT? > Assist steps/running boards are reimbursable if they are not available as a regular GM production option or dealer-installed accessory, regardless of whether the vehicle is bought out of dealer stock or ordered. A maximum $200 GM Mobility reimbursement is allowed. A physician’s signature and description of your disability/limitation are required. Call the GM Mobility Assistance Center if you have questions.

CAN I INCORPORATE GM MOBILITY REIMBURSEMENT INTO THE TERMS OF MY

VEHICLE SALES CONTRACT? > It may be possible. Contact your Chevrolet, Buick or GMC dealer for details.

*Leased vehicles must have lessor’s written approval prior to adapting vehicle. †Call 1-888-4-ONSTAR/1-888-466-7827 (TTY 1-877-248-2080).Visit onstar.com for coverage map, details and system limitations.

AM I ABLE TO USE THE GM MOBILITY REIMBURSEMENT WITH OTHER FACTORY

REBATES AND INCENTIVES? > Yes. The GM Mobility reimbursement incentive may be combined with other publicly offered incentive programs that are in effect at the time of purchase or lease, including most fleet and commercial incentives.

HOW SOON AFTER I PURCHASE OR LEASE MY NEW VEHICLE DO I HAVE TO COMPLETE THE AFTERMARKET ADAPTIVE EQUIPMENT INSTALLATION AND APPLY FOR GM MOBILITY REIMBURSEMENT? > To take advantage of the GM

Mobility Reimbursement Program, you must have the vehicle adapted and submit a claim within 6 months of the date of purchase/lease.

ARE THERE ANY OTHER WAYS I CAN OFFSET THE COST OF PURCHASING AUTO- MOTIVE ADAPTIVE EQUIPMENT? > The cost of durable aftermarket automotive adaptive equipment for use by persons with disabilities may be offset with federal income tax credits and deductions, state sales and use tax deductions, funding through state rehabilitation vocational agencies, and medical insurance providers. Consult with your tax advisor/preparer, appropriate state social service agency, and/or insurance provider to see what benefits you may be eligible for. Your savings could be substantial.

PLEASE CONTACT US FOR MORE INFORMATION ABOUT SPECIFIC PRODUCTS AND SERVICES.

Call 1-800-323-9935	Call 1-888-466-7827
(TTY 1-800-833-9935)	(TTY 1-877-248-2080)
or visit gmmobility.com	or visit onstar.com

11CRDMOBREM01	6
M O B I L I T Y