Account Reassignment & Refund Request Form

Company:

Date:

EFIN:

Company Contact Person:

Company Phone #:

Refund Amount:

Reason For Moving:

Dear,

(Software Company)

I will be utilizing Nexus United Service Bureau software this year. Thank you for your immediate attention to this matter.

Name:

Signed:

Date:

NEXUS UNITED, INC.

2201 SEACREST BLVD

DELRAY BEACH, FL 33444

(Toll Free) (855) 639-8740 (F) (866)815-1645