Account Closure

Form

Date________________

Bank Name_________________________________________________________

Bank Address________________________________________________________

City_______________________ State_______ Zip Code____________________

Please close the account # _________________________ and send a check for the remaining balance to the address below.

If you have any questions about this request, please contact me at:

Phone # ____________________ Phone # ____________________

(Day) (Evening)

Sincerely,

Signature _________________________ Name ____________________________

(Please print)

Address____________________________________________________________

City_______________________ State_____ Zip Code____________________