(g) The information required in the model
form may be modified only as described in this subsection.
(1) Name of the covered entity or group of
affiliated covered entities or institutions providing the notice. Insert the
name of the covered entity providing the notice or a common identity of
affiliated covered entities or institutions jointly providing the notice on the
form wherever name of covered entity appears.
(2) Page one instruction.
(A) Last revised date. The covered entity
must insert in the upper right-hand corner the date on which it last revised
the notice. The information must appear in minimum 8-point font as "rev.
(month/year)" using either the name or number of the month, for example "rev.
July 2009" or "rev. 7/09."
(B)
General instructions for the "What?" box.
(i)
The bulleted list identifies the types of personal information the covered
entity collects and shares. All covered entities must use the term "Social
Security number" in the first bullet.
(ii) Covered entities must use at least five
of the following terms to complete the bulleted list: income, account balances,
payment history, transaction history, transaction or loss history, credit
history, credit scores, assets, investment experience, credit-based insurance
scores, insurance claim history, medical information, overdraft history,
purchase history, account transactions, risk tolerance, medical-related debts,
credit card or other debt, mortgage rates and payments, retirement assets,
checking account information, employment information, and wire transfer
instructions.
(C)
General instructions for the disclosure table. The left column lists reasons
for sharing or using personal information. Each reason correlates to a specific
legal provision described in the instructions in subparagraph (D) of this
paragraph. In the middle column, each covered entity must provide a "Yes" or
"No" response that accurately reflects its information-sharing policies and
practices with respect to the reason listed on the left. In the right column,
each covered entity must provide in each box one of the following three
responses, as applicable, that reflects whether a consumer can limit such
sharing:
(i) "Yes" if it is required to or
voluntarily provides an opt out;
(ii) "No" if it does not provide an opt out;
or
(iii) "We don't share" if it
answers "No" in the middle column. Only the sixth row, "For our affiliates to
market to you," may be omitted at the option of the covered entity as described
in the instructions in subparagraph (D)(vi) of this paragraph.
(D) Specific disclosures and
corresponding legal provisions.
(i) For our
everyday business purposes. This reason incorporates sharing information under
§
RSA
22.18 and §
RSA
22.19 of this title (relating to Exceptions
to Notice and Opt Out Requirements for Disclosure of Nonpublic Personal
Financial information for Processing and Servicing Transactions and Other
Exceptions to Notice and Opt Out Requirements for Disclosure of Nonpublic
Personal Financial Information) and with service providers under §
RSA
22.17 of this title (relating to Exception to
Opt Out Requirements for Disclosure of Nonpublic Personal Financial Information
for Service Providers and Joint Marketing), other than the purposes specified
in the instructions in clause (ii) or (iii) of this subparagraph.
(ii) For our marketing purposes. This reason
incorporates sharing information with service providers by a covered entity for
its own marketing under §
RSA
22.17 of this title. A covered entity that
shares for this reason may choose to provide an opt out.
(iii) For joint marketing with other
financial companies. This reason incorporates sharing information under joint
marketing agreements between two or more covered entities or financial
institutions and with any service provider used in connection with such
agreements under §
RSA
22.17 of this title. A covered entity that
shares for this reason may choose to provide an opt out.
(iv) For our affiliates' everyday business
purposes - information about transactions and experiences. This reason
incorporates sharing information specified in §603(d)(2)(A)(i) and
§603(d)(2)(A)(ii) of the FCRA. A covered entity that shares for this
reason may choose to provide an opt out.
(v) For our affiliates' everyday business
purposes - information about creditworthiness. This reason incorporates sharing
information under §603(d)(2)(A)(iii) of the FCRA. A covered entity that
shares for this reason must provide an opt out.
(vi) For our affiliates to market to you.
This reason incorporates sharing information specified in §624 of the
FCRA. This reason may be omitted from the disclosure table when the covered
entity does not have affiliates, or does not disclose personal information to
its affiliates; the covered entity's affiliates do not use personal information
in a manner that requires an opt out; or the covered entity provides the
affiliate marketing notice separately. Covered entities that include this
reason must provide an opt out of indefinite duration. A covered entity that
must provide an affiliate marketing opt out, but does not include that opt out
in the model form under this clause, must comply with §624 of the FCRA and
Insurance Code Chapter 601 and 28 TAC Subchapter A, including §§
RSA
22.8-
RSA
22.12 of this title (relating to Initial
Privacy Notice, Annual Privacy Notice, Information to be Included in Privacy
Notices, Form of Opt Out Notice to Consumers and Opt Out Methods, and Revised
Privacy Notices, respectively), with respect to the initial notice and opt out
and any subsequent renewal notice and opt out. A covered entity not required to
provide an opt out under this subparagraph may elect to include this reason in
the model form.
(vii) For
nonaffiliates to market to you. This reason incorporates sharing described in
§22.11 and §22.12(a)(1) - (4) of this title. A covered entity that
shares personal information for this reason must provide an opt out.
(E) To limit our sharing. A
covered entity must include this section of the model form only if it provides
an opt out. The word "choice" may be written in either the singular or plural,
as appropriate. Covered entities must select one or more of the applicable opt
out methods described: telephone, for example, by a toll-free number; a
website; or use of a mail-in opt out form. Covered entities may include the
words "toll-free" before telephone, as appropriate. A covered entity that
allows consumers to opt out online must provide either a specific web address
that takes consumers directly to the opt out page or a general web address that
provides a clear and conspicuous direct link to the opt out page. The opt out
choices made available to the consumer who contacts the covered entity through
these methods must correspond accurately to the "Yes" responses in the third
column of the disclosure table. In the part titled "Please note," covered
entities may insert a number that is 30 or greater in the space marked "(30)."
Instructions on voluntary or state privacy law opt out information are in the
instructions in subparagraph (G)(v) of this paragraph.
(F) Questions box. Customer service contact
information must appear, as appropriate, where "phone number" or "website"
appears. Covered entities may elect to provide either a phone number, such as a
toll-free number, or a web address, or both. Covered entities may include the
words "toll-free" before the telephone number, as appropriate.
(G) Mail-in opt out form. Covered entities
must include this mail-in form only if they state in the "To limit our sharing"
box that consumers can opt out by mail. The mail-in form must provide opt out
options that correspond accurately to the "Yes" responses in the third column
in the disclosure table. Covered entities that require customers to provide
only name and address may omit the section identified as "account #." Covered
entities that require additional or different information, for example, a
random opt out number or a truncated account number, to implement an opt out
election should modify the "account #" reference accordingly. This includes
covered entities that require customers with multiple accounts to identify each
account to which the opt out should apply. A covered entity must enter its opt
out mailing address in the far right of the Version 3: Model Form with Mail-In
Opt Out Form. A covered entity must enter its opt out mailing address below the
Version 4: Optional Mail-In Form. The reverse side of the mail-in opt out form
must not include any content of the model form.
(i) Joint accountholder. Only covered
entities that provide their joint accountholders the choice to opt out for only
one accountholder, in accord with the instructions in paragraph (3)(A)(v) of
this subsection, must include in the far left column of the mail-in form the
following statement: "If you have a joint account, your choice(s) will apply to
everyone on your account unless you mark below. Apply my choice(s) only to me."
The word "choice" may appear in either the singular or plural, as appropriate.
Covered entities that provide insurance products or services, provide this
option, and elect to use the model form may substitute the word "policy" for
"account" in this statement. Covered entities that do not provide this option
may eliminate this left column from the mail-in form.
(ii) FCRA §603(d)(2)(A)(iii) opt out. If
the covered entity shares personal information under §603(d)(2)(A)(iii) of
the FCRA, it must include in the mail-in opt out form the following statement:
"Do not share information about my creditworthiness with your affiliates for
their everyday business purposes."
(iii) FCRA §624 opt out. If the covered
entity incorporates §624 of the FCRA in accord with the instructions in
subparagraph (D)(vi) of this paragraph, it must include in the mail-in opt out
form the following statement: "Do not allow your affiliates to use my personal
information to market to me."
(iv)
Nonaffiliate opt out. If the covered entity shares personal information under
§22.14(a)(1) - (4) of this title (relating to Limits on Disclosure of
Nonpublic Personal Financial Information to Nonaffiliated Third Parties), it
must include in the mail-in opt out form the following statement: "Do not share
my personal information with nonaffiliates to market their products and
services to me."
(v) Additional opt
outs. Covered entities that use the disclosure table to provide opt out options
beyond those required by federal law must provide those opt outs in this
section of the model form. A covered entity that chooses to offer an opt out
for its own marketing in the mail-in opt out form must include one of the two
following statements: "Do not share my personal information to market to me."
or "Do not use my personal information to market to me." A covered entity that
chooses to offer an opt out for joint marketing must include the following
statement: "Do not share my personal information with other financial
institutions to jointly market to me."
(H) Barcodes. A covered entity may elect to
include a barcode, a tagline, or both as an internal identifier in 6-point font
at the bottom of page one, as needed for information internal to the
institution, so long as these do not interfere with the clarity or text of the
form.
(3) Page two
instructions.
(A) General instructions for
the questions. Certain of the questions may be customized as follows:
(i) "Who is providing this notice?" A covered
entity may omit this question where only one covered entity provides the model
form and that covered entity's name clearly appears in the title on page one.
Two or more covered entities or financial institutions that jointly provide the
model form must use this question to identify themselves as required by §
RSA
22.13(g) of this title
(relating to Delivery). Where the list of covered entities or financial
institutions exceeds four lines, the covered entity must describe in the
response to this question the general types of covered entities or financial
institutions jointly providing the notice and must separately identify those
covered entities or financial institutions, in minimum 8-point font, directly
following the "Other important information" box, or, if that box is not
included in the covered entity's form, directly following the "Definitions."
The list may appear in a multi-column format.
(ii) "How does (name of covered entity)
protect my personal information?" The covered entity may only provide
additional information about its safeguarding practices following the
designated response to this question. This may include information about the
covered entity's use of "cookies" or other measures it uses to safeguard
personal information. Covered entities are limited to a maximum of 30
additional words.
(iii) "How does
(name of covered entity) collect my personal information?" Covered entities
must use at least five of the following terms to complete the bulleted list for
this question: open an account, deposit money, pay your bills, apply for a
loan, use your credit or debit card, seek financial or tax advice, apply for
insurance, pay insurance premiums, file an insurance claim, seek advice about
your investments, buy securities from us, sell securities to us, direct us to
buy securities, direct us to sell your securities, make deposits or withdrawals
from your account, enter into an investment advisory contract, give us your
income information, provide employment information, give us your employment
history, tell us about your investment or retirement portfolio, tell us about
your investment or retirement earnings, apply for financing, apply for a lease,
provide account information, give us your contact information, pay us by check,
give us your wage statements, provide your mortgage information, make a wire
transfer, tell us who receives the money, tell us where to send the money, show
your government-issued ID, show us your driver's license, or order a commodity
futures or option trade. Covered entities that collect personal information
from their affiliates, credit bureaus, or both, must include after the bulleted
list the following statement: "We also collect your personal information from
others, such as credit bureaus, affiliates, or other companies." Covered
entities that do not collect personal information from their affiliates or
credit bureaus but do collect information from other companies must include the
following statement instead: "We also collect your personal information from
other companies." Only covered entities that do not collect any personal
information from affiliates, credit bureaus, or other companies can omit both
statements.
(iv) "Why can't I limit
all sharing?" Covered entities that describe state privacy law provisions in
the "Other important information" box must use the bracketed sentence: "See
below for more on your rights under state law." Other covered entities must
omit this sentence.
(v) "What
happens when I limit sharing for an account I hold jointly with someone else?"
Only covered entities that provide opt out options must use this question.
Other covered entities must omit this question. Covered entities must choose
one of the following two statements to respond to this question: "Your choices
will apply to everyone on your account," or "Your choices will apply to
everyone on your account-unless you tell us otherwise." Covered entities that
provide insurance products or services and elect to use the model form may
substitute the word "policy" for "account" in these statements.
(B) General instructions for the
definitions. The covered entity must customize the space below the responses to
the three definitions in this area of the form. This specific information must
be in italicized lettering to set off the information from the standardized
definitions.
(i) Affiliates. As required by
§
RSA
22.10(b)(3) of this title,
where (affiliate information) appears, the covered entity must:
(I) if it has no affiliates, state: "(name of
covered entity) has no affiliates";
(II) if it has affiliates but does not share
personal information, state: "(name of covered entity) does not share with our
affiliates"; or
(III) if it shares
with its affiliates, state, as applicable: "Our affiliates include companies
with a (common corporate identity of covered entity) name; financial companies
such as (insert illustrative list of companies); nonfinancial companies, such
as (insert illustrative list of companies); and others, such as insert
illustrative list."
(ii)
Nonaffiliates. As required by §
RSA
22.10(d) of this title,
where (nonaffiliate information) appears, the covered entity must:
(I) if it does not share with nonaffiliated
third parties, state: "(name of covered entity) does not share with
nonaffiliates so they can market to you"; or
(II) if it shares with nonaffiliated third
parties, state, as applicable: ''Nonaffiliates we share with can include (list
categories of companies such as mortgage companies, insurance companies, direct
marketing companies, and nonprofit organizations)."
(iii) Joint marketing. As required by §
RSA
22.17 of this title, where (joint marketing)
appears, the covered entity must:
(I) if it
does not engage in joint marketing, state: "(name of covered entity) doesn't
jointly market"; or
(II) if it
shares personal information for joint marketing, state, as applicable: "Our
joint marketing partners include (list categories of companies, such as credit
card companies)."
(C) General instructions for the "Other
important information" box. This box is optional. The space provided for
information in this box is not limited. Only the following types of information
may appear in this box:
(i) State,
international privacy law information, or both; or
(ii) Acknowledgment of receipt form;
or
(iii) Both (i) and
(ii).