________
________
________

________

Sent via: ________

________
Attn: ________
________
________

RE: Notice of Cancellation of Membership — Account No. ________

To Whom It May Concern:

§ 1. Purpose of Notice. This letter constitutes formal written notice of my election to cancel and terminate the Membership agreement (the “Agreement”) entered into on or about ________ between the undersigned (the “Member”) and ________ (the “Provider”), associated with account number ________. This notice is given in accordance with the terms of the Agreement and any applicable federal and state consumer-protection and contract laws.

§ 2. Statement of Cancellation. Pursuant to the cancellation provisions of the Agreement, I hereby exercise my right to terminate the Agreement and to discontinue any and all recurring charges, automatic renewals, or recurring electronic fund transfers authorized in connection therewith, effective as of the Cancellation Date set forth in § 4 below.

§ 3. Reason(s) for Cancellation. The Member is canceling for the following reason(s):

________

§ 4. Effective Date. I request that this cancellation take effect on ________ (the “Cancellation Date”). If the Agreement or applicable law requires a minimum notice period before cancellation becomes effective, I request that the cancellation take effect upon the earliest date permitted on or after the Cancellation Date.

Lorem ipsum dolor sit amet consectetur adipiscing elit sed do eiusmod tempor incididunt ut labore et dolore magna aliqua ut enim ad minim veniam quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat duis aute irure dolor in reprehenderit voluptate velit esse cillum dolore eu fugiat nulla pariatur lorem ipsum dolor sit amet consectetur adipiscing elit sed do eiusmod tempor incididunt ut labore et.

§ 6. Cancellation Fee. Enclosed with this letter is payment of any applicable cancellation or early-termination fee in the amount of $________, tendered without waiver of, and expressly reserving, all rights and remedies should such fee be determined to be unenforceable under applicable law.

§ 7. Refund of Remaining Balance. Please refund the prepaid, unused, or remaining balance on my Membership in the amount of $________ by Check made payable to ________, to be issued no later than ________.

§ 8. Written Confirmation. Please provide written confirmation of the cancellation of my Membership, including the effective date and the disposition of any refund or final balance, within thirty (30) days of your receipt of this letter.

Lorem ipsum dolor sit amet consectetur adipiscing elit sed do eiusmod tempor incididunt ut labore et dolore magna aliqua ut enim ad minim veniam quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat duis aute irure dolor.

§ 10. Contact Information. If you have any questions or require additional information to process this cancellation, I can be reached by telephone at ________, by email at ________, or by mail at:

________
________

I look forward to your prompt written response.

Regards,

...............................................
________
Date: ________

Enclosure(s): ________