Date:

To whom it may concern:

I request to have my name removed from your marketing lists. Here is the information you have asked me to include in my request:

FIRST, MIDDLE & LAST NAME (List all name variations, including Jr., Sr., etc.)
____________________________________________________

CURRENT MAILING ADDRESS
____________________________________________________
____________________________________________________
____________________________________________________

PREVIOUS MAILING ADDRESS (Fill in your previous mailing address if you have moved in the last 6 months.)
____________________________________________________
____________________________________________________
____________________________________________________

SOCIAL SECURITY NUMBER (optional)
____________________________________________________

DATE OF BIRTH
____________________________________________________

Thank you for your prompt handling of my request.

____________________________________________________
Signature