I certify that the information provided below relates to a single identity that is one of the following:
- An individual for which I have legal guardianship or power of attorney,
- or a deceased member of my family.
Please add all variations of your name (i.e. nick names, former names, married name, common spellings/mis-spellings), all phone numbers, email addresses, P.O. Boxes and street addresses that you regularly use or are associated with, and which you would like added to the Opt-Out request, in the additional information/comments field below.
* = Required fields