Creditor
123 Creditor's Address
Creditor's City, State, Zip

RE: Account No. XXXX XXXX XXXX XXXX

Dear Sir or Madam:

I am writing to request that the above-referenced credit card account be closed, effective immediately. Please notate this account in any reports to the relevant consumer reporting agencies as "account closed by cardholder request."

My destroyed card is enclosed. Please notify me in writing to confirm that this account has been closed as requested.

Should you have any questions or need additional information, please contact me at (XXX) XXX-XXXX.

Very truly yours,

Cardholder's Name
Your address

Billing address (if different from your mailing address)

source:http://credit.about.com/od/credit101/ss/closecreditcard_4.htm