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PTO Form 2196 (Rev 9/2005) OMB No. 06510056 (Exp 9/30/2017)Revocation of Attorney/Domestic Representative and/or Appointment of Attorney/Domestic Representative The table below presents the data as

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01

Fill out the withdrawal request form completely with accurate information.

02

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03

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05

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Sign and date the withdrawal request form before submitting it to the appropriate department or authority.

Who needs request for withdrawal as?

01

Anyone who wants to receive funds from their account or terminate a financial relationship with a particular institution may need to submit a request for withdrawal.

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