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Opt-Out Form

This document is a data opt out and removal request form. It instructs individuals on how to submit their information to have their data removed from the company's website. The form requires individuals to provide their full legal name, aliases, date of birth, address, email/phone number, reason for request, a copy of photo ID, and signature. Once completed, the form should be faxed or mailed to the company's data opt out department for processing within 30 days.

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879 views

Opt-Out Form

This document is a data opt out and removal request form. It instructs individuals on how to submit their information to have their data removed from the company's website. The form requires individuals to provide their full legal name, aliases, date of birth, address, email/phone number, reason for request, a copy of photo ID, and signature. Once completed, the form should be faxed or mailed to the company's data opt out department for processing within 30 days.

Uploaded by

Aggregate Data
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Data Opt Out & Removal Request Form

In order for us to assist you in the removal of your identifying information from our
website it is vital that you submit this form fully filled out as instructed below. We
understand that you may have some security concerns when sending us your information.
We wish to reassure you that we abide by very stringent security protocols. All
information you provide through the data opt out request process is ONLY used for the
purposes of removing data from our databases. The information you submit to us is not
stored, shared, sold, or used for any marketing purposes. It is used strictly to assist in the
facilitation of the data removal request. Please visit our Privacy Policy page for more
information.
Note: The following information is required to successfully remove your listing as it
appears on our website:

Your Information
1. Full Legal Name
(First) (Middle) (Last) (Jr., Sr., III)

2. Other Names or Aliases (If different from above)


(First) (Middle) (Last) (Jr., Sr., III)

3. Date of Birth
(day/month/year)

4. Current Address
City
Zip Code

State
At the above address since
(month/year)

5. Email Address or Phone Number

(This information may be used to contact you in the case your form is improperly filled out or
incomplete)

Reason for Request


Check all that apply for items 6 - 9:
6. Please select the reason for your request as listed below:
You are a state, local or federal law enforcement officer or public official and
your position exposes you to a threat of death or serious bodily harm
You are a victim of identity theft
You are at risk of physical harm
You have evidence the record is incorrect or expunged (please attach copy of
appropriate documents along with this form)
You prefer to prohibit your information from being made available through our
service.
It may further help us locate the information you wish removed/withheld if you provide
us such details as the location of the data in question in a form of website/URL link.

Please be sure to include a copy of your state issued ID along with copies of any
applicable court orders.
7. Copy of a valid government-issued photo-identification card (drivers license,
state-issued ID card or your passport).
8.
Please be sure to include a copy of any legal/court order or document when
applicable.
9.
Information such as First Name, Last Name, DOB, City, State and Zip Code are
necessary and will only be used with this data removal request.
Once you have checked off everything on the list above please fax this form along
with a copy of your state issued ID and any applicable documents to Fax:
1-617-933-9946. You may also mail us your request to Data Opt Out Department,
P.O. Box 990043 Boston, MA 02199

Please allow upwards of 30 days for us to fully process your Data Opt Out request.
Please note: We do not process Data Opt Out requests by email or over the phone. We
may not be able to process incomplete requests which are missing proof of identification
and/or vital information such as name, address and date of birth.
Although most information is usually removed or blocked permanently, we do not
guarantee the information will not be available again in the future as we are not in direct
control of the information distributed and obtained from official public
records/government or third party sources. It is for this reason that we recommend you
contact the custodian of the original record to request it be removed or corrected.
This request will not remove information from third party websites.
Please be aware that we are not a consumer reporting agency as defined by the FCRA,
as we do not provide any data for use in credit, insurance, or employment screening. We
explicitly prohibit the use of our service and the data it supplies for such purposes.
_________________________________
Signature

_________________________________
Date

InfoPay
Data Opt Out Department
P.O. Box 990043
Boston, MA 02199

This Opt-Out form must be signed either by the person requesting to be opted out or by
their legal representative. If you are signing this as their legal representative you must
include a power of attorney stating such.

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