INDEPENDENCEFN.COM

INDEPENDENCE FINANCIAL NETWORK D/B/A INDEPENDENCE FINANCIAL

Limit the Use of Sensitive Personal Information

Data Request Form

Residents of certain states have the right to limit our use of their sensitive personal information as explained in our Privacy Policy.

If you would like to limit use of your sensitive personal information, please email us at info@independencefn.com, or write to us at 845 Third Ave 6th Floor Suite 653 New York, NY 10022, Attention: Legal Department, or complete and submit the form below. While we will try to honor your request as soon as possible, please allow up to 15 business days for us to process your request.

If you are an authorized agent of a requesting consumer, you must provide a written authorization from the consumer or a copy of a lawful power of attorney that permits you to submit the opt out request on the consumer’s behalf. You may provide that written authorization to us via email at info@independencefn.com after submitting the opt our request. We may contact you or the consumer on whose behalf you claim to act to verify your authorization.

Additional information about how we use and disclose personal information, including the types of third parties to whom we sell personal information, and methods by which you may contact us with questions, can be found in our Privacy Policy. Before submitting your correction request, we urge you to read and consider the Privacy Policy.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

What are your preferred contact methods for questions about your request?*

Phone Call

Text Message

Mail

How do you want to receive our response? *

Mail

Are you submitting this request as an authorized agent for the above consumer? *

Yes

By submitting this form, I certify that I am the above-named individual or a person authorized by the above-named individual to submit this form on their behalf. I understand that Independence Financial Network, LLC may contact me to obtain identity verification and validate this request.

I consent