AUTHORIZATION TO CLOSE ACCOUNT

Previous Financial Institution: __________________________________________
Address: __________________________________________
 
This form gives you authorization to close my account #__________ and forward the balance to us at the address provided. Please make the check payable First Heritage Bank for benefit of (Name):
Name: __________________________________________
 
Your prompt attention to this request is appreciated. Thank you.
 
Signature: __________________________________________
Date: __________________________________________
Joint Signature: __________________________________________
Date: __________________________________________
 

First Heritage Bank
801 S. Fremont
Shenandoah, IA 51601
Phone: 712-246-5118
Fax:712-246-3554
www.fhbshen.com