[Date]

[Your address] 

[Name of company]

[Company's address as shown in the privacy notice]

RE: Opt-Out Instructions for Account #______________

Dear [name if given in the privacy notice]:

Following are my instructions with regard to your information sharing and sales policies:

1. You do not have my permission to share my personally identifiable information with 
nonaffiliated third party companies or individuals. I am asserting my rights under the 
Financial Services Modernization Act (the Gramm-Leach-Bliley Act) to opt-out of any sharing 
or sales of my information by your company.

2. You do not have my permission to share information about my creditworthiness with any 
affiliate of your company. I am asserting my rights under the Fair Credit Reporting Act to 
opt-out of any sharing of this information by your company.

3. [Optional] I do not wish to receive marketing offers from your company or its affiliates. 
Please delete my name from all marketing lists and databases.
[Optional] Your company's privacy notice states you may otherwise use my information as 
"permitted by law." I wish to limit other uses of my personal information by your company 
and its affiliates. In particular:

* You do not have my permission to disclose any information about me, including transaction 
and experience information, to your affiliates.

* You do not have my permission to disclose any information about me in connection with direct 
marketing agreements between your company and another company.

Thank you for respecting my privacy and honoring my choices regarding my customer information. 
Please acknowledge your intention to comply with my request for privacy of my personal financial 
and other information

Sincerely,

[Your signature]

[Your name]

[Keep a copy of the letter for yourself.]