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REQUEST TO CLOSE ACCOUNT

Print and complete this form, then mail to the bank which holds the account you are requesting to be closed.

TO

Complete the information below using the information for the bank which holds the account you are requesting be closed.

Name ________________________________________________________________________ Address ______________________________________________________________________ City _______________________________ State ______________________ Zip ____________

My Information

Your Name ____________________________________________________________________ Address ______________________________________________________________________ City _______________________________ State ______________________ Zip ____________ Phone Number ________________________________

Request to Close My Account(s)

I hereby authorize you to close out the following accounts in my name at your bank: Checking Account Number: ________________________________________ Savings Account Number: _________________________________________ Other Accounts:_______________________________________________________________ Please leave $__________________ in my account to cover any outstanding transactions that have not cleared. If I have remaining funds, please send me a check. Thank you for your assistance with this matter. Sincerely, Signature ______________________________________________ Date ______________

Information

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