To receive your Visa prepaid card by mail follow these conditions of acceptance:1) Purchase select Genuine GM New Transfer Case, 6T70/75 Transaxles or 5.7L GM Parts Service Engines and

have it installed at an Independent Service Center between November 7, 2016 and December 31, 2016.2) Complete all information requested on this form accurately and legibly.

3) Make a clean, legible copy of your Invoice/Repair Order including the shop identification and circlethe purchase(s).

4) Mail a copy of your Invoice/Repair Order and this completed rebate form to the address below.

Mail to:

5) To check the status of your submission, visit the “My Rebate Status” section at www.mycertifiedservicerebates.com.

GM Powertrain RebatesOffer Number 66023PO Box 6970 Mesa, AZ 85216

Program Dates: 11/07/2016 - 12/31/2016 GM Powertrain Rebates$100 or $200 GM Visa Prepaid Card Offer

Offer valid for customers who purchase and install a Genuine GM Part at a participating shop located in the United States. Qualifying parts must be purchased during a single transaction, and excludes sales tax and labor. Offer valid on select 5.7L GM Parts Service Engines, Transaxles and New Transfer Cases (see part #'s above). Maximum mail-in rebate amount not to exceed $400. In order to receive the mail-in rebate qualifying purchases must satisfy the rebate requirements as outlined on the 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 and U.S. territories. Fleet and Commercial customers are eligible for this offer. Limit one (1) redemption per address 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. Rebate paid in the form of a Visa prepaid card. The Visa prepaid card is not redeemable for cash or usable at any ATM. Terms and Conditions apply to the card. Subject to applicable law, a monthly maintenance fee of $3 (USD) applies, but it is waived for the first twelve months after the card is issued. Cards are issued by Citibank, N.A. pursuant to a license from Visa U.S.A. Inc. and managed by Citi Prepaid Services. Cards will not have cash access and can be used everywhere Visa debit cards are accepted. General Motors reserves the right to substitute a check of equal value in lieu of a Visa prepaid card at its discretion. Please allow up to 8 weeks for delivery of the rebate debit card. These parts are designed and intended to be used with experts supervising their installation and use, to help assure the proper and safe operation of the vehicle. ©2016 General Motors. All Rights Reserved.

If you have not received your prepaid card within 8 weeks after the postmark date of your qualified submission,or if you have questions about your submission, call (844) 656-5369 weekdays, 7am to 11pm EST.

Submission must be postmarked by January 15, 2017.

Customer Information Section *Denotes Required Field

*Address

*First Name

*Shop Name *Shop Zip Code *Date of Service (MM/DD/YY)

*Invoice/Repair Order Number

*Last Name

*City *State *Zip Code

Email Phone

To read the GM Privacy Statement, go to www.gm.com/privacy.

*Service Advisor Name: *Service Advisor Email Address:

IMPORTANT: Check the box next to the 8 digit GM Number for the part(s) purchased on your Invoice/Repair Order.

❏ 17803936❏ 17803937❏ 17803988❏ 17804031❏ 17804032❏ 17804035❏ 19257073❏ 19303651❏ 19332848❏ 19332849❏ 19332850

❏ 19332851❏ 19332854❏ 19332855❏ 19332856❏ 19332857❏ 19332858❏ 19332859❏ 19332860❏ 19332861❏ 19332863❏ 19332864

❏ 19332867❏ 19332868❏ 19332869❏ 19332870❏ 19332871❏ 19332872❏ 19332873❏ 19332874❏ 19332875❏ 19332877❏ 19332878

❏ 19332879❏ 19332880❏ 19334257❏ 19334259❏ 19354261❏ 19354262❏ 24255765❏ 24256463❏ 24260670❏ 24260832❏ 24262790

❏ 24263200❏ 24264091

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

$100 REBATE ON 6T70 TRANSAXLE

$100 REBATE ON 6T75 TRANSAXLE

❏ 19303655❏ 19332852❏ 19332853❏ 19332862❏ 19332876❏ 24250057

$100 REBATE ON5.7L GM PARTS

SERVICE ENGINES

❏ 10067353❏ 12568758❏ 12530282❏ 12530283

$200 REBATE ONNEW TRANSFER CASE

❏ 23164315❏ 23188338❏ 23188339❏ 23188341❏ 24238186❏ 24238187❏ 24238188❏ 24238189

❏ 24238191❏ 24238192❏ 24238193❏ 24240015❏ 24240016❏ 84109394

*Denotes Required Field