Name*

Middle Initial

Address*

Phone*

Email address that you wish to “opt-out”*

Last 4 Digits of Social Security Number*

Date of Birth*

Hunt Henriques Account Number (if known)

REQUEST – (Pursuant to Regulation F) I hereby declare under penalty of perjury that the information above is true and correct and that I (the individual described above) am the individual that is providing the information above.

Today’s Date*

Signature*

Name of Authorized Entity and/or Name of Person Signing Above:*