The letter below is intended to be sent to your financial institution in order to protect the privacy of your financial records.

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:  

Copyright Family Guardian Fellowship