[INSTRUCTIONS:  TO BE USED ONLY IN THE EVENT THAT THE AGENCY DISCLOSES INFORMATION TO NON-AFFILIATED THIRD PARTIES AS NOTED IN PARAGRAPH III B OF SAMPLE IIAM PRIVACY NOTICE AND DISCLOSURE]

[NAME OF AGENCY]

OPT-OUT FORM

If you chose to exercise your right to opt-out, you must mail this form to: [insert address].  This form must be post-marked within 30 days in order to be valid.  If not mailed to us within the 30-day period, your opt-out will not be valid and we can share the information listed below:

______           Do not share my non-public personal information to non-affiliated    third parties for any purposes not required or  permitted by law.

Customer signature:_______________________________     Date:  ____________

                                    Please print

Full Name:          _______________________________

Address:            _______________________________

City:                ____________________State: ___________Zip Code:_________

**Special Note: It is true that an agent may share information if a person does not return the opt-out form within 30 days, but if the person does return the form after the 30 day period, the agent must stop sharing information from the time the form is received.