Notice to Remove Name From List

Date: _________________
_______________________________
_______________________________
[name and address of list maintainer]

To Whom It May Concern:

Please permanently remove all members of this household from all lists you maintain, sell, trade, share, or use in any other capacity for direct marketing, telemarketing, credit card pre-screening, or any other promotional opportunity.

Name 1:	___________________________
Address:	___________________________
___________________________
Date of birth:	_______________________
Social Security Number:	______________

Name 2:	___________________________
Address:	___________________________
___________________________
Date of birth:	_______________________
Social Security Number:	______________

Name 3:	___________________________
Address:	___________________________
___________________________
Date of birth:	_______________________
Social Security Number:	______________

Sincerely,

__________________________________________________
Signature
_______________________________
Print name