Opt Out Response Form

Member Number: ________________________________________________________

Member Name: __________________________________________________________
(please print)

I have read the Privacy Notice disclosure provided by the credit union, and would like to exercise my right to opt out, as permitted by law. Please opt me out for the following:

• Nonpublic Personal Information

NOTE: Anyone listed on the account may elect to opt out on the account on behalf of all account holders.

Please opt me out from the following accounts:

• All accounts on which I am listed; or
• List specific accounts:
  • Account # __________________
  • Account # __________________
  • Account # __________________
  • Account # __________________
  • Account # __________________
  • Account # __________________

_____________________________________
Member Signature

_____________________________________
Date

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