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PACT ACCOUNT CANCELLATION REQUEST

Please cancel the following PACT account(s): PACT Account Number:_________________________ _________________________ _________________________ Purchaser Name: ______________________________ Purchaser Address: _____________________________ ______________________________________________ (This is the address where the refund check will be mailed.) Beneficiary Name: _____________________________ Reason for Cancellation: _____ Personal _____Death of Beneficiary ____Beneficiary Scholarship _______PACT Lawsuit Settlement Agreement (The $75 Cancellation Fee is waived through 9-30-11) I certify by signing below that the information I have provided on this form is true and correct. I understand that submission of this information and this certification are treated as made under oath by law and subject to penalties for perjury. (Ala. Code, § 13A-10-100(a) (3) and § 13A-10-102.) Signature of Purchaser: ______________________________________ Date: _________________ Daytime Telephone Numbers with area codes: ______________________________________

Please fax to (800) 830-7390 or mail to: PACT P.O. Box 12865 Birmingham, AL 35202-2865

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