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Enter Today's Date

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Financial Institution Name

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Financial Institution Address

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State City Zip Code

To Whom It May Concern:

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I hereby authorize

to close the following account:

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Routing Number:

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Account Number:

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Account Type: Select Account TypeCheckingSavingsMoney Market

Please send a check for the closing balance to

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Your Name

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Address

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State City Zip Code

Sincerely,

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Your Name

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Company Name

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State City Zip Code