Fact Sheet 24a Addendum:
Short Form Opt Out Letter

TO: [COMPANY NAME]

Street :

Address:

City:

State and Zip Code:

ATTN: "OPT OUT" Department

FROM: [FULL NAME]

FULL STREET ADDRESS

CITY

STATE AND ZIP CODE

RE: MY ACCOUNT(S) WITH YOU

[List Name/Type of Account & Acct. Nos.]

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:
   
   
2. Please do not disclose personally identifiable information with your non-affiliated third-party companies or individuals.
   
   
3. Please do not disclose my creditworthiness to any affiliate.
   
   
4. Further, I request the following, even though it may not be required by law:
   
   
5. Please, do not disclose my transaction and experience information to any affiliate of yours.
   
   
6. Please, do not disclose any information about me in connection with marketing agreements between you and any other company.
   
   
7. Thank you for respecting my privacy and honoring my choices regarding my customer information. I would appreciate confirmation from you regarding my requests.
   
   
   

SIGNATURE & DATE:  

Ý