Account Closing Request Form

To Whom It May Concern:

This request form is to authorize the closing of the following account(s). Please forward all funds remaining in the account(s) per the instruction selected below.

Checking Account Number (10 digits):

Savings Account Number (10 digits):

Other Account Number:

Please send a check to me at the address listed below.

Please send a check to Westbury Online or Merrill Community Bank FBO said customer at:

Westbury Online

15 E. Wisconsin Ave.,

P.O. Box 159

Tomahawk, WI 54487

Merrill Community Bank

907 E. Main St.,

Merrill, WI 54452

Name on Account(s)

Address on Account(s)

City

State

Zip Code

Thank you for processing this request immediately!
If you have any questions, please contact me at the phone number or address below.

Primary Account Holder Information

Account Holder/Authorized Signer Signature

Social Security Number

Secondary Account Holder Information

Account Holder/Authorized Signer Signature

Social Security Number

Today's Date:

Your Address

City

State

Zip Code

Home Phone Number

Work Phone Number

Your Cell Phone Number

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