Request To Close Account

To whom it may concern:

I hereby request the following bank account I/we maintain with your financial institution to be closed:

Financial Institution Name: ______________________________________________________

Account Number(s): _______________________ ______________________________

Account Owner(s): ________________________________________________

Address: ________________________________________________________

Phone: _________________________________________________________

Payment Schedule:

q Immediately liquidate all assets and send the proceeds

q Send proceeds of accounts listed above

Payment Method:

Please make check payable to First Star Bank FBO: _________________________

Mailed to the following branch address: __________________________

__________________________

Account Owner(s) Signature: ___________________________ Date: ________________

Signature: ___________________________ Date: ________________