Legal Opt Out Disclosure Form

LEGAL OPT OUT DISCLOSURE FORM

This Legal Opt Out Disclosure Form (the "Form") is made and entered into as of Date: by and between Company Name: with principal address: and Client Name: with mailing address: .

RECITALS

WHEREAS, Company provides products or services for which certain disclosures and information-sharing practices are applicable and, in the ordinary course, provides notice of such disclosures to clients and customers; and

WHEREAS, Client desires to elect an opt-out from one or more specified disclosures or programs offered or required by Company, and Company is willing to document such election subject to the terms and conditions set forth in this Form; and

WHEREAS, the parties intend by this Form to set forth the manner, scope, and legal effect of Client's opt-out election.

NOW, THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable consideration, the sufficiency of which is hereby acknowledged, the parties agree as follows:

1. DEFINITIONS

1.1 "Opt-Out" means the affirmative election by Client to decline participation in, or receipt of, one or more discrete disclosures, communications, or information-sharing arrangements identified in Section 2 of this Form.

1.2 "Disclosures" means notices, reports, sharing of personal data, marketing communications, arbitration/class-action provisions, or other communications as described in Section 2.

2. SCOPE OF OPT-OUT ELECTION

Client elects to opt out of the following disclosures, each item checked below constituting a separate, severable election:

Marketing communications and third-party marketing information-sharing.

Receipt of electronic notices and invoices (Client elects paper-only notices).

Inclusion in class-action or collective-action settlements or waivers (opt out of class treatment where applicable).

Sharing of personally identifiable information with affiliates or non-affiliated third parties for purposes other than performance of services.

3. ACKNOWLEDGMENTS AND REPRESENTATIONS

3.1 Client acknowledges that certain opt-outs may limit or modify Company’s ability to deliver services or communications. Client further acknowledges that opting out may result in delayed or altered receipt of notices, offers, or service-related information.

3.2 Client represents and warrants that the information provided on this Form is true, complete, and provided voluntarily, and that Client has authority to make the opt-out election for the individual or entity identified as Client.

4. EFFECTIVE DATE; DURATION; WITHDRAWAL

4.1 The opt-out selections made on this Form shall be effective as of the Effective Date set forth above, or, if no Effective Date is provided, upon Company’s receipt of a fully executed copy of this Form.

4.2 The opt-out will remain in effect until withdrawn in writing by Client. Withdrawal will be effective thirty (30) days after Company’s receipt of written notice of withdrawal unless a different effective date is expressly agreed in writing.

4.3 Certain opt-out elections may be irreversible under applicable law or may be subject to contractual limitations; Client acknowledges and accepts those conditions where applicable.

5. CONFIDENTIALITY; USE OF INFORMATION

5.1 Company shall use Client’s personal information only as permitted by law and as necessary to perform obligations under any underlying agreement between the parties, except where Client has validly opted out as provided herein.

5.2 Nothing in this Form shall require Company to take any action that would violate applicable legal or regulatory requirements or that would reasonably expose Company to liability.

6. NOTICES

Notices given under this Form shall be delivered in writing to the addresses provided above and shall be effective upon receipt, provided that notice by electronic mail shall be effective only if acknowledged by the receiving party in writing.

7. REMEDIES; LIMITATION OF LIABILITY

7.1 Each party acknowledges that a breach of this Form may cause the other party irreparable harm for which monetary damages may be inadequate; accordingly, the non-breaching party shall be entitled to seek equitable relief, including injunctive relief, in addition to any other remedies at law or in equity.

7.2 Except for willful misconduct or gross negligence, neither party shall be liable to the other for consequential, incidental, punitive, or special damages arising out of or relating to this Form.

8. MISCELLANEOUS

Governing Law: This Form shall be governed by and construed in accordance with the laws of the State of without regard to principles of conflicts of law.

Entire Agreement: This Form, together with any contemporaneous written agreements expressly incorporated herein, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous understandings and agreements, whether written or oral.

Severability: If any provision of this Form is held to be invalid, illegal or unenforceable in any respect, the validity, legality and enforceability of the remaining provisions shall not be affected or impaired thereby.

Amendment: This Form may be amended or modified only by a written instrument signed by both parties.

Waiver: No waiver of any breach of any provision of this Form shall be deemed a waiver of any subsequent breach of the same or any other provision.

Counterparts: This Form may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one and the same instrument.

CERTIFICATION

The undersigned certifies that they are duly authorized to execute this Form on behalf of the party identified, that they have read and understand the scope and effect of the opt-out elections selected herein, and that the information provided is true and correct.

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