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: