REQUEST TO CLOSE ACCOUNT(S)

Attn: Customer Support Personnel

	(Name of Financial Institution)
	(Mailing Address of Financial Institution)

I request the following account(s) listed below be closed. Please draft a cashiers check reflecting the balance of funds remaining in the below listed account(s) and deliver it to me by mail. By signing below, I acknowledge that I am owner and/or signer on the listed account(s). Should you need to contact me, please refer to the contact information found below.

Thank you.

Owner or Signer	Co-owner or Signer (if applicable)
(Signature as it appears on account documents)	(Signature as it appears on account documents if applicable)
Date

Please close accounts:   Account Number Account Type Account Number Account Type Account Number Account Type Account Number Account Type

You may contact me via: telephone at  . The best time to reach me is . email at  mail at