South Carolina Code of Regulations › Chapter 69 - DEPARTMENT OF INSURANCE › Subchapter 69-58 - Privacy of Consumer Financial and Health Information › Article VI - ADDITIONAL PROVISIONS › Appendix B - FEDERAL MODEL PRIVACY FORM

Current through Register Vol. 48, No. 6, June 28, 2024
Licensees, including a group of financial holding company
				  affiliates that use a common privacy notice, may use the Federal Model Privacy
				  Form, if the Form is accurate for each institution that uses the Form. (Note
				  that disclosure of certain information, such as assets, income and information
				  from a consumer reporting agency, may give rise to obligations under the
				  federal Fair Credit Reporting Act, such as a requirement to permit a consumer
				  to opt of disclosures to affiliates or designation as a consumer reporting
				  agency if disclosures are made to nonaffiliated third parties.)
General Instructions
1. How the Model Privacy Form is used.
(a) The Model Form may be used, at the option of a
				  "licensee", including a group of licenses or other financial institutions that
				  use a common privacy notice, to meet the content requirements of the privacy
				  notice and opt-out notice set forth in Sections 7 and
				  8 of this Regulation.
(b) The Model Form is a standardized form, including page
				  layout, content, format, style, pagination, and shading. Licensees seeking to
				  obtain the safe harbor through use of the Model Form may modify it only as
				  described in these Instructions.
(c) Note that disclosure of certain information, such as
				  assets, income, and information from a consumer reporting agency, may give rise
				  to obligations under the federal Fair Credit Reporting Act (FCRA), codified at
				  15 U.S.C. §§ 1681-1681x, such
				  as a requirement to permit a consumer to opt out of disclosures to affiliates,
				  or designation as a consumer reporting agency if disclosures are made to
				  nonaffiliated third parties.
(d) The word "customer" may be replaced by the word "member,"
				  whenever it appears in the Model Form, as appropriate.
2. The Contents of the Model Privacy Form
The Model Form consists of two pages, which may be printed on
				  both sides of a single sheet of paper or may appear on two separate pages.
				  Where a licensee provides a long list of licensees or financial institutions at
				  the end of the Model Form in accordance with Instruction B3(a)(i), or provides
				  additional information in accordance with Instruction B3(c) and such list or
				  additional information exceeds the space available on Page Two of the Model
				  Form, such list or additional information may extend to a third page.
(a) Page One. The first page consists of the following
				  components:
(1) Date last revised (upper right-hand corner)
(2) Title
(3) Key frame (Why? What? How?)
(4) Disclosure table ("Reasons we can share your personal
				  information")
(5) "To limit our sharing" box, as needed, for the licensee's
				  opt-out information
(6) "Questions" box, for customer service contact
				  information
(7) Mail-in opt-out form, as needed
(b) Page Two. The second page consists of the following
				  components:
(1) Heading (Page 2)
(2) Frequently Asked Question ("Who we are" and "What we
				  do")
(3) Definitions
(4) "Other important information" box, as needed
3. The format of the Model Privacy Form
The format of the Model Form may be modified only as
				  described below:
(a) Easily readable type font. Licensees that use the Model
				  Form must use an easily readable type font. While a number of factors together
				  produce easily readable font, licensees are required to use a minimum of
				  10-point font (unless otherwise expressly permitted in these Instructions) and
				  sufficient spacing between lines.
(b) Logo. A licensee may include a corporate logo on any page
				  of the notice, so long as it does not interfere with the readability of the
				  Model Form or the space constraints of each page.
(c) Page size and orientation. Each page of the Model Form
				  must be printed in portrait orientation, the size of which must be sufficient
				  to meet the layout and minimum font size requirements, with sufficient white
				  space on the top, bottom, and sides of the content.
(d) Color. The Model Form must be printed on white or light
				  color paper (such as cream) with black or other contrasting ink color. Spot
				  color may be used to achieve visual interest, so long as the color contrast is
				  distinctive and the color does not detract from the readability of the Model
				  Form. Logos may also be printed in color.
(e) Languages. The Model Form may be translated into
				  languages other than English.
B. Information Required in the Model Privacy Form
The information in the Model Form may be modified only as
				  described below:
1. Name of licensee or group of affiliated licensees or
				  institutions providing the notice.
Insert the name of the licensee providing the notice, or a
				  common identity of the affiliated licenses or financial institutions jointly
				  providing the notice on the form, wherever [name of licensee] appears.
2. Page One
(a) Last revised date. The licensee must insert in the upper
				  right-hand corner the date on which the notice was last revised. The
				  information shall appear in minimum 8-point font as "rev. [month/year]" using
				  either the name or number of the month, such as "rev. July 2016" or "rev.
				  7/16."
(b) General instructions for the "What?" box.
(i) The bulleted list identifies the types of personal
				  information that the licensee collects and shares. All licensees must use the
				  term "Social Security Number" in the first bullet.
(ii) A licensee must use five (5) of the following terms, to
				  complete the bulleted list: income; account balances; payment history;
				  transaction history; transaction or loss history; credit history; credit
				  scores; assets; investment experiences; credit -based insurance scores;
				  insurance claim history; medical information; overdraft history; purchase
				  history; account transactions; risk tolerance; medical related debts; credit
				  card or other debt; mortgage rates and payments; retirement assets; checking
				  account information; employment information; wire transfer instructions.
(c) General instructions for the disclosure table. The left
				  column lists reasons for sharing or using personal information. Each reason
				  correlates to a specific legal provision described in Paragraph 2(d) of this
				  Instruction. In the middle column, each licensee must provide a "Yes" or "no"
				  response that accurately reflects its information-sharing policies and
				  practices with respect to the reason listed on the left. In the right column,
				  each licensee must provide in each box one of the following three (3)
				  responses, as applicable, that reflects whether a consumer can limit such
				  sharing:
"Yes," if it is required to or voluntarily provides an
				  opt-out; "No," if it does not provide an opt-out; or
"We don't share," if it answers "No" in the middle
				  column.
Only the sixth row ("For our affiliates to market to you")
				  may be omitted at the option of the licensee. See Paragraph 2(d)(6) of this
				  instruction.
(d) Specific disclosures and corresponding legal
				  provisions
(i) For our everyday business purposes. This reason
				  incorporates sharing information under Sections 16 and 17 of this Regulation
				  and with service providers pursuant to Section
				  15 of this Regulation, other than the
				  disclosures described in Paragraphs (2)(d)(ii) or (2)(d)(iii) of this
				  instruction.
(ii) For our marketing purposes. This reason incorporates
				  sharing information with service providers by a licensee for its own marketing
				  pursuant to Section
				  15 of this Regulation. A licensee that
				  shares for this reason may choose to provide an opt-out.
(iii) For joint marketing with other financial companies.
				  This reason incorporates sharing information under joint marketing agreements
				  between 2 or more licensees or financial institutions and with any service
				  provider used in conjunction with such agreement pursuant to Section 15 of this
				  Regulation. A licensee that shares for this reason may choose to provide and
				  opt-out.
(iv) For our affiliates' everyday business purposes-
				  information about transactions and experiences. This reason incorporates
				  sharing information specified in Sections 603(d)(2)(A)(i) and (ii) of the FCRA.
				  A licensee that shares information for this reason may choose to provide an
				  opt-out.
(v) For our affiliates' everyday business purposes-
				  information about creditworthiness. This reason incorporates sharing
				  information pursuant to Section 603(d)(2)(A)(iii) of the FCRA. A licensee that
				  shares information for this reason must provide an opt-out.
(vi) For our affiliates to market to you. This reason
				  incorporates sharing information specified in Section
				  24 of the FCRA. This reason may be
				  omitted from the disclosure table when" the licensee does not have affiliates
				  (or does not disclose personal information to its affiliates); the licensee's
				  affiliates do not use personal information in a manner that requires an
				  opt-out; or the licensee provides the affiliate marketing notice separately.
				  Licensees that include this reason must provide an opt-out of indefinite
				  duration. A licensee that is required to provide an affiliate marketing
				  opt-out, but does not include that opt-out in the Model Form under this part,
				  must comply with Section 624 of the FCRA and this Regulation with respect to
				  the initial notice and opt-out and any subsequent renewal notice and opt-out. A
				  licensee not required to provide an opt-out under this subparagraph may elect
				  to include this reason in the Model Form.
(vii) For nonaffiliates to market to you. This reason
				  incorporates sharing described in Sections 8 and
				  12(a) of this
				  Regulation. A licensee that shares personal information for this reason must
				  provide an opt-out.
(e) To limit our sharing. A licensee must include this
				  section of the Model Form only if it provides an opt-out. The word "choice" may
				  be written in either the singular or plural, as appropriate. Licensees must
				  select one or more of the applicable opt-out methods described: telephone, such
				  as by a toll-free number; a web site; or use of a mail-in opt-out form.
				  Licensees may include the word "toll-free" before telephone, as appropriate. A
				  licensee that allows consumer to opt out online must provide either a specific
				  web address that takes consumers directly to the opt-out page or a general web
				  address that provides a clear and conspicuous direct link to the opt-out page.
				  The opt-out choices made available to the consumer who contacts the licensee
				  through these methods must correspond accurately to the "Yes" response in the
				  third column of the disclosure table. In the part entitled "Please note,"
				  licensees may insert a number that is 30 days or greater in the space marked
				  "[30]." Instructions on voluntary or state privacy law opt-out information are
				  in Paragraph 2(g)(v) of these Instructions.
(f) Questions box. Customer service contact information must
				  be inserted as appropriate where [phone number] or [web site] appear. Licenses
				  may elect to provide either a phone number, such as a toll-free number, or a
				  web address, or both. Licensees may include the words "toll-free" before the
				  telephone number, as appropriate.
(g) Mail-in opt-out form. Licensees must include this mail-in
				  form only if they state in the "To limit our sharing" box that consumers can
				  opt out by mail. The mail-in form must provide opt-out options that correspond
				  accurately to the "Yes" responses in the third column of the disclosure table.
				  Licensees that require consumers to provide only name and address may omit the
				  section identified as "[account #]." Licensees that require additional or
				  different information, such as a random opt-out election should modify the
				  "[account#]" reference accordingly. This includes licensees that require
				  customers with multiple accounts to identify each account to which the opt-out
				  should apply. A licensee must enter its opt-out mailing address in the far
				  right of this form (see version3); or below the form (see version 4). The
				  reverse side of the mail-in opt-out form must not include any content of the
				  Model Form.
(i) Joint accountholder. Only licensees that provide their
				  joint accountholders the choice to opt out for only one accountholder, in
				  accordance with Paragraph 3(a)(5) of these Instructions, must include in the
				  far left column of the mail-in form the following statement:
If you have a joint account, your choice(s) will apply to
				  everyone on your account unless you mark below [] Apply my choice(s) only to
				  me.
The word "choice" may be written in either the singular or
				  plural, as appropriate. Licensees that provide insurance products or services
				  provide this option, and elect to use the Model Form may substitute the word
				  "policy" for "account" in this statement. Licensees that do not provide this
				  option may eliminate this left column from the mail-in form.
(ii) FRCA Section 603(d)(2)(A)(iii) opt-out. If the licensee
				  shares personal information pursuant to Section 603(d)(A)(iii) of the FCRA, it
				  must include in the mail-in opt-out form the following statement:
[] Do not share information about my creditworthiness with
				  you affiliates for their everyday business purposes.
(iii) FCRA Section 624 opt-out. If the licensee uses Section
				  624 of the FCRA, in accordance with paragraph 2(d)(6) of these Instructions, it
				  must include in the mail-in opt-out form the following statement:
[] Do not allow your affiliates to use my personal
				  information to market to me.
(iv) Nonaffiliate opt-out. If the licensee shares personal
				  information pursuant to Section 12(a) of this Regulation], it must include in
				  the mail-in opt-out form the following statement:
[] Do not share my personal information with nonaffiliates to
				  market their products and services to me.
(v) Additional opt-outs. Licensees that use the disclosure
				  table to provide opt out options beyond those required by Federal law must
				  provide those opt-outs in this section of the Model Form. A licensee that
				  chooses to offer an opt-out for its own marketing in the mail-in opt-out form
				  must include one of the two following statements:
[] Do not share my personal information to market to me.
				  OR
[] Do not use my personal information to market to me.
A licensee that chooses to offer an opt-out for joint
				  marketing must include the following statement:
[] Do not share my personal information with other financial
				  institutions to jointly market to me.
(h) Barcodes. A licensee may elect to include a barcode
				  and/or "tagline" (an internal identifier) in 6-point type at the bottom of page
				  one, as needed for information internal to the licensee, so long as these do
				  not interfere with the clarity or text of the form.
3. Page Two
(a) General Instructions for the Questions. Certain Questions
				  on the Model Form may be customized as follows:
(i) "Who is providing this notice?" This question may be
				  omitted where only one licensee provides the Model Form and that licensee is
				  clearly identified in the title on Page One. Two or more licensees or financial
				  institutions that jointly provide the Model Form must use this question to
				  identify themselves as required by Section
				  11(F) of this
				  Regulation. Where the list of licensees or financial institutions exceeds four
				  (4) lines, the licensee must describe in the response to this question the
				  general types of licensees or financial institutions jointly providing the
				  notice and must separately identify those licensees or financial institutions,
				  in minimum 8-point font, directly following the "Other important information"
				  box, or, if that box is not included in the licensee's form, directly following
				  the "Definitions." The list may appear in a multi-column format.
(ii) "How does [name of licensee] protect my personal
				  information?" The licensee may only provide additional information pertaining
				  to its safeguards practices following the designated response to this question.
				  Such information may include information about the licensee's use of cookies or
				  other measures it uses to safeguard personal information. Licensees are limited
				  to a maximum of 30 additional words.
(iii) "How does [name of licensee] collect my personal
				  information?" Licensees must use five (5) of the following terms to complete
				  the bulleted list for this question: open an account; deposit money; pay your
				  bills; apply for a loan; use your credit or debit card; seek financial or tax
				  advice; apply for insurance; pay insurance premiums; file an insurance claim;
				  seek advice about your investments; buy securities from us; sell securities to
				  us; direct us to buy securities; direct us to sell your securities; make
				  deposits or withdrawals from your account; enter into an investment advisory
				  contract; give us you income information; provide employment information; tell
				  us about your investment or retirement portfolio; tell us about your investment
				  or retirement earnings; apply for financing; apply for a lease; provide account
				  information; give us you contact information; pay us by check; give us your
				  wage statements ; provide your mortgage information; make a wire transfer; tell
				  us who receives the money; tell us where to send the money; show your
				  government-issued ID; show your driver's license; order a commodity futures or
				  option trade.
Licensees that collect personal information from their
				  affiliates and/or credit bureaus must include the following statement after the
				  bulleted list; "We also collect your personal information from others, such as
				  credit bureaus, affiliates, or other companies." Licensees that do not collect
				  personal information from their affiliates or credit bureaus but do collect
				  information from other companies must include the following statement instead:
				  "We also collect your personal information from other companies." Only
				  licensees that do not collect any personal information from affiliates, credit
				  bureaus, or other companies can omit both statements.
(iv) "Why can't I limit all sharing?" Licensees that describe
				  state privacy law provisions in the "Other important information" box must use
				  the bracketed sentence: "See below for more on your rights under state law."
				  Other licensees must omit this sentence.
(v) "What happens when I limit sharing for an account I hold
				  jointly with someone else?" Only licensees that provide opt-out options must
				  use this question. Other licensees must omit this question. Licensees must
				  choose one of the following tow statements to respond to this question: "Your
				  choices will apply to everyone on your account - unless you tell us otherwise."
				  Licensees may substitute the word policy" for "account" in these
				  statements.
(b) General Instructions for the Definitions. The licensee
				  must customize the space below the responses to the three definitions in this
				  section. This specific information must be in italicized lettering to set off
				  the information from the standardized definitions.
(i) Affiliates. As required by Section
				  7(A)(3) of this Regulation, where
				  [affiliate information] appears, the licensee must:
(a) If it has no affiliates, state: "[name of licensee] has
				  no affiliates";
(b) If it has affiliates but does not share personal
				  information with them, state: "[name of licensee] does not share with our
				  affiliates"; or
(c) If it shares with its affiliates, state, as applicable:
				  "Our affiliates include companies with a [common corporate identity of
				  licensee] name; financial companies such as [insert illustrative list of
				  companies]; nonfinancial companies, such as [insert illustrative list of
				  companies]; and others, such as [insert illustrative list]."
(ii) Nonaffiliates. As required by Section
				  7(c)(3) of this
				  Regulation, where [nonaffiliated information] appears, the licensee
				  must:
(a) If it does not share with nonaffiliated third parties,
				  state: "[name of licensee] does not share with nonaffiliates so they can market
				  to you"; or
(b) If it shares with nonaffiliated third parties, state, as
				  applicable: "Nonaffiliates we share with can include [list categories of
				  companies such as mortgage companies, insurance companies, direct marketing
				  companies, and nonprofit organizations]."
(iii) Joint Marketing. As required by Section
				  15 of this Regulation, where [joint
				  marketing] appears, the licensee must:
(a) If it does not engage in joint marketing, state: "[name
				  of licensee] doesn't jointly market", or
(b) If it shares personal information for joint marketing,
				  state, as applicable: "Our joint marketing partners include [list categories of
				  companies such as credit card companies]."
(c) General instruction for the "Other important information"
				  box. This box is optional. The space provided for information in this box is
				  not limited, and an additional page may be used if necessary. Only the
				  following types of information can appear in this box:
(i) State and/or international privacy law information;
				  and/or
(ii) A form by which the consumer may acknowledge receipt of
				  the notice.
Version 1:
Model Form with No Opt-Out
FACTS
WHAT DOES [Name of Licensee]
DO WITH YOUR PERSONAL
								INFORMATION?
Why?
Financial companies choose how they share your
								personal information. Federal law gives consumers the right to limit some but
								not all sharing. Federal law also requires us to tell you how we collect,
								share, and protect your personal information. Please read this notice carefully
								to understand what we do.
What?
The types of personal information we collect and
								share depend on the product or service you have with us. This information can
								include:
Social Security number and [income]
[account balances] and [payment history]
[credit history] and [credit scores]
When you are
no longer
our
								customer, we continue to share your information as described in this
								notice.
How?
All financial companies need to share
customers'
personal information to run their everyday business. In
								the section below, we list the reasons financial companies can share their
customers'
personal information; the reasons [name of financial
								institution
]
chooses to share; and whether you can limit this
								sharing.
Reasons we can share your personal
								information
Does [name of licensee] share?
Can you limit this sharing?
For our everyday business
								purposes
-
such as to process your transactions, maintain your
								account(s), respond to court orders and legal investigations, or report to
								credit bureaus
For our marketing purposes-
to offer our products and services to you
For joint marketing with other financial
								companies
For our affiliates' everyday business
								purposes-
information about your transactions and
								experiences
For our affiliates' everyday business
								purposes-
information about your creditworthiness
For our affiliates to market to
								you
For nonaffiliates to market to
								you
Questions?
Call [phone number] or go to [web site]
Who we are
Who is providing this notice?
[insert]
What we do
How does [name of licensee] protect my personal
								information?
To protect your personal information from
								unauthorized access and use, we use security measures that comply with federal
								law. These measures include computer safeguards and secured files and
								buildings.
[insert]
How does [name of licensee] collect my personal
								information?
We collect your personal information, for example,
								when you
[open an account] or [deposit money]
[pay your bills] or [apply for a loan]
[use your credit or debit card]
[We also collect your personal information from
								other companies.]
OR
[We also collect your personal information from
								others, such as credit bureaus, affiliates, or other companies.]
Why can't I limit all sharing?
Federal law gives you the right to limit only
								sharing for affiliates' everyday business purposes - information about your
								creditworthiness affiliates from using your information to market to you
								sharing for nonaffiliates to market to you
State laws and individual companies may give you
								additional rights to limit sharing. [See below for more on your rights under
								state law.]
Definitions
Affiliates
Companies related by common ownership or control.
								They can be financial and nonfinancial companies.
[affiliate information]
Nonaffiliates
Companies not related by common ownership or
								control. They can be financial and nonfinancial companies.
[nonaffiliated information]
Joint Marketing
A formal agreement between nonaffiliated financial
								companies that together market financial products or services to you.
[joint marketing information]
Other important information
[insert other important information]
Version 2: Model Form with Opt-Out by telephone and/or
				  Online
Rev. [insert date]
FACTS
WHAT DOES [Name of Licensee]
DO WITH YOUR PERSONAL
								INFORMATION?
Why?
Financial companies choose how they share your
								personal information. Federal law gives consumers the right to limit some but
								not all sharing. Federal law also requires us to tell you how we collect,
								share, and protect your personal information. Please read this notice carefully
								to understand what we do.
What?
The types of personal information we collect and
								share depend on the product or service you have with us. This information can
								include:
Social Security number and [income]
[account balances] and [payment history]
[credit history] and [credit scores]
When you are
no longer
our
								customer, we continue to share your information as described in this
								notice.
How?
All financial companies need to share customers'
								personal information to run their everyday business. In the section below, we
								list the reasons financial companies can share their customers' personal
								information; the reasons [name of financial institution] chooses to share; and
								whether you can limit this sharing.
Reasons we can share your personal
								information
Does [name of licensee] share?
Can you limit this sharing?
For our everyday business
								purposes
-
such as to process your transactions, maintain your
								account(s), respond to court orders and legal investigations, or report to
								credit bureaus
For our marketing purposes-
to offer our products and services to you
For joint marketing with other financial
								companies
For our affiliates' everyday business
								purposes-
information about your transactions and
								experiences
For our affiliates' everyday business
								purposes-
information about your creditworthiness
For our affiliates to market to
								you
For nonaffiliates to market to
								you
To limit our sharing
Call [phone number] - our menu will prompt you
								through your choice(s) or Visit us online: [website]
Please note:
If you are a
new
customer, we can
								begin sharing your information [30] days from the date we sent this notice.
								When you are no longer our customer, we continue to share your information as
								described in this notice. However, you can contact us at any time to limit our
								sharing.
Questions?
Call
[
phone number] or go to [web
								site]
Who we are
Who is providing this notice?
[insert]
What we do
How does
[name of licensee]
protect my
								personal information?
To protect your personal information from
								unauthorized access and use, we use security measures that comply with federal
								law. These measures include computer safeguards and secured files and
								buildings.
[insert]
How does
[name of licensee]
collect my
								personal information?
We collect your personal information, for example,
								when you
[open an account] or [deposit money]
[pay your bills] or [apply for a loan]
[use your credit or debit card]
[We also collect your personal information from
								other companies.]
OR
[We also collect your personal information from
								others, such as credit bureaus, affiliates, or other companies.]
Why can't I limit all sharing?
Federal law gives you the right to limit only
								sharing for affiliates' everyday business purposes - information about your
								creditworthiness affiliates from using your information to market to you
								sharing for nonaffiliates to market to you
State laws and individual companies may give you
								additional rights to limit sharing
.
[See below for more on your
								rights under state law.]
What happens when I limit sharing for an account I
								hold jointly with someone else?
[Your choices will apply to everyone on your
								account.] OR
[Your choices will apply to everyone on your
								account - unless you tell us otherwise.]
Definitions
Affiliates
Companies related by common ownership or control.
								They can be financial and nonfinancial companies.
[affiliate information]
Nonaffiliates
Companies not related by common ownership or
								control. They can be financial and nonfinancial companies.
[nonaffiliated information]
Joint Marketing
A formal agreement between nonaffiliated financial
								companies that together market financial products or services to you.
[joint marketing information]
Other important information
[insert other important information]
FACTS
WHAT DOES [Name of Licensee]
DO WITH YOUR PERSONAL
								INFORMATION?
Why?
Financial companies choose how they share your
								personal information. Federal law gives consumers the right to limit some but
								not all sharing. Federal law also requires us to tell you how we collect,
								share, and protect your personal information. Please read this notice carefully
								to understand what we do.
What?
The types of personal information we collect and
								share depend on the product or service you have with us. This information can
								include:
Social Security number and [income]
[account balances] and [payment history]
[credit history] and [credit scores]
How?
All financial companies need to share customers'
								personal information to run their everyday business. In the section below, we
								list the reasons financial companies can share their customers' personal
								information; the reasons [name of financial institution] chooses to share; and
								whether you can limit this sharing.
Reasons we can share your personal
								information
Does [name of licensee] share?
Can you limit this sharing?
For our everyday business
								purposes-
such as to process your transactions, maintain your
								account(s), respond to court orders and legal investigations, or report to
								credit bureaus
For our marketing purposes-
to offer our products and services to you
For joint marketing with other financial
								companies
For our affiliates' everyday business
								purposes-
information about your transactions and
								experiences
For our affiliates' everyday business
								purposes-
information about your creditworthiness
For our affiliates to market to
								you
For nonaffiliates to market to
								you
To limit our sharing
Call
[phone number]
- our menu will
								prompt you through your choice(s) or Visit us online:
[website] or
Mail the form below
Please note:
If you are a
new
customer, we can
								begin sharing your information
[30]
days from the date we sent
								this notice. When you are
no longer
our customer, we continue
								to share your information as described in this notice. However, you can contact
								us at any time to limit our sharing.
Questions?
Call
[phone number]
or go to
[web site]
Mail-in Form
Leave Blank
OR
[If you have a joint account, your choice(s) will
								apply to everyone on your account unless you mark below.
[] Apply my choices only to me]
Mark any/all you want to limit:
[] Do not share information about my
								creditworthiness with your affiliates for their everyday business
								purposes.
[] Do not allow your affiliates to use my personal
								information to market to me.
[] Do not share my personal information with
								nonaffiliates to market their products and services to me.
Name
Address City, State, Zip
[Account #]
Mail To:
[Name of Licensee]
[Address]
[City],[ST][ZIP]
Who we are
Who is providing this notice?
[insert]
What we do
How does
[name of licensee]
protect my
								personal information?
To protect your personal information from
								unauthorized access and use, we use security measures that comply with federal
								law. These measures include computer safeguards and secured files and
								buildings.
[insert]
How does
[name of licensee]
collect my
								personal information?
We collect your personal information, for example,
								when you
[open an account]
or
[deposit
								money]
[pay your bills]
or
[apply for a
								loan]
[use your credit or debit card]
[We also collect your personal information
								from other companies.]
OR
[We also collect your personal information
								from others, such as credit bureaus, affiliates, or other
								companies.]
Why can't I limit all sharing?
Federal law gives you the right to limit only
								sharing for affiliates' everyday business purposes - information about your
								creditworthiness affiliates from using your information to market to you
								sharing for nonaffiliates to market to you
State laws and individual companies may give you
								additional rights to limit sharing
. [See below for more on your rights
								under state law.]
What happens when I limit sharing for an account I
								hold jointly with someone else?
[Your choices will apply to everyone on your
								account
.] OR
[Your choices will apply to everyone on your account
								- unless you tell us otherwise.]
Definitions
Affiliates
Companies related by common ownership or control.
								They can be financial and nonfinancial companies.
[affiliate information]
Nonaffiliates
Companies not related by common ownership or
								control. They can be financial and nonfinancial companies.
[nonaffiliated information]
Joint Marketing
A formal agreement between nonaffiliated financial
								companies that together market financial products or services to you.
[joint marketing information]
Other important information
[insert other important information]
Version 4: Optional Mail-in Form
Mail-in Form
Leave Blank
OR
[If you have a joint account, your choice(s) will
								apply to everyone on your account unless you mark below.
[] Apply my choices only to me]
Mark any/all you want to limit:
[] Do not share information about my
								creditworthiness with your affiliates for their everyday business
								purposes.
[] Do not allow your affiliates to use my personal
								information to market to me.
[] Do not share my personal information with
								nonaffiliates to market their products and services to me.
Name
Address City, State, Zip
[Account #]
Mail To:
[Name of Licensee]
[Address 1], [Address 2],
[City],[ST][ZIP]