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ATTENTION: COMPANY NAME: ADDRESS: CITY, STATE, ZIP: As of the date signed below, I, hereby notify you, that I am revoking the automatic payment authorization agreement we had dated in the amount of
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As of the date signed below, I, , hereby notify you, , that I am revoking the automatic payment authorization agreement we had dated in the amount of for account number: frequently asked questions

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As of form date refers to the date in which the information on the form is accurate and valid.
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