MILL CREEK AGENCY, INC.

OPT-OUT FORM

Please read the test below and decide whether you wish to exercise your right to opt out of the information sharing described.  If you choose to exercise your right to opt out, you must mail this form back to us at          97 Main St - Suite R, Stony Brook, NY  11790.  Your response must be postmarked no later than 30 days from the date you received this notice from us in person in order to for it to be valid.  If you do not mail this form back or do not mail it back within 30 days, you have not exercised your opt-out right, and we can share the information described.

I wish to exercise my right to opt out of Mill Creek Agency's sharing of nonpublic personal information about me to nonaffiliated parties for purposes other than those that are permitted by law.

 

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