TO [COMPANY NAME]:
Street :
Address :
City:
State and Zip Code:

ATTN: "OPT OUT" Department

MY FULL NAME IS:
FULL STREET ADDRESS
CITY
STATE AND ZIP CODE

RE: These accounts. I am listing my name, the name of my account, and my account numbers here:

________________________________________________________

________________________________________________________

________________________________________________________

1. I am asserting my rights under the Financial Services Modernization Act and the Fair Credit Reporting Act to "opt out" of the following two uses of my personal information:
a. You do not have permission to disclose personally identifiable information with your non-affiliated third-party companies or individuals.
b. You do not have permission to disclose my creditworthiness to any affiliate.

2. I am further instructing you:
a. Do not disclose any of my transaction and experience information to any affiliate of yours.
b. Do not disclose any information about me in connection with marketing agreements between you and any other company.

3. Please respond to me in writing stating that you will comply with these instructions. If I have not received a letter within thirty days specifically denying my instructions, I will assume your records have been noted to comply with this letter.

I am mailing this in a sealed envelope, and I am NOT including my social security number. I believe my name and account number identify me sufficiently.

SIGNATURE AND DATE:

 

[MAIL IN A SEALED ENVELOPE TO EACH COMPANY. Use only your return address (not your ss number or account number) on the return envelope.]