Opt Out Form

---
name: opt-out-form
language: en
description: Drafts opt-out forms and notices of exclusion for class actions, settlements, arbitration clauses, and privacy programs. Covers party identification, election language, consequence statements, signature blocks, and submission instructions per governing orders or contracts (FRCP 23, arbitration windows, CCPA/GDPR). Use when preparing opt-out paperwork, notices of exclusion, settlement opt-outs, or arbitration opt-out letters.
---

# Opt-Out Form

Produces a ready-to-execute opt-out form tailored to the governing order, settlement, or contract.

## Gather Before Drafting

1. Governing instrument (court order, settlement agreement, arbitration clause, program rules)
2. Opt-out deadline — postmark vs receipt; time zone if electronic
3. Submission channel(s) — mail, email, portal; required address/URL
4. Case/program identifiers — caption, case number, settlement name, claim/account ID
5. Party data — legal name, address, email, phone, proof of membership/transaction
6. Representative authority (if minors, incapacitated persons, or entities)

## Form Structure

Build in this order:

1. **Header/caption** — court name, case caption, case number, deadline
2. **Party identification** — name, address, contact, claim/reference ID, membership proof
3. **Election statement** — first-person opt-out with specific program/case name
4. **Consequences acknowledgment** — forfeiture of settlement benefits, retention of individual rights
5. **Signature block** — signature, printed name, date, representative capacity if applicable
6. **Submission instructions** — recipient, deadline, postmark/receipt rule, proof-of-submission guidance

### Required Fields

| Field | Required | Notes |
|---|---|---|
| Full legal name | Yes | Must match account/claim records |
| Mailing address | Yes | For confirmation notices |
| Email | Conditional | If allowed/required by program |
| Claim/account/reference ID | Yes | As specified in governing instrument |
| Proof of membership | Conditional | Transaction date/ID, purchase, policy number |
| Representative capacity | Conditional | Title/relationship and authority statement |

### Election Language Checklist

- [ ] Clear first-person election: "I elect to opt out and exclude myself from [program/case]."
- [ ] Specific program name and case caption
- [ ] Statement of non-participation in settlement/award
- [ ] Reservation of individual rights (if allowed) — do not expand beyond opt-out scope

### Signature Block Checklist

- [ ] Signature line (handwritten or electronic per governing instrument)
- [ ] Printed name and date of execution
- [ ] Representative capacity block (if applicable)
- [ ] Certification statement if required: "I declare under penalty of perjury …"

## Template

```text
[COURT NAME]
[CASE CAPTION]
Case No. [NUMBER]

OPT-OUT FORM / NOTICE OF EXCLUSION
Deadline: [DATE] ([POSTMARK/RECEIPT] by [TIME TZ] if applicable)

1. Identifying Information
Name: ________________________________
Mailing Address: ______________________
Email: _______________________________
Phone: _______________________________ (if required)
Claim/Account/Reference ID: ___________
Proof of Membership/Transaction: ______

2. Election to Opt Out
I hereby elect to opt out of and exclude myself from [FULL NAME OF
SETTLEMENT/CLASS/PROGRAM] in [CASE NAME/PROGRAM]. I understand that
by opting out, I will not receive any settlement benefits and will
not be bound by any settlement or judgment in this matter.

3. Acknowledgment of Consequences
I understand that I retain any rights to pursue my own claims, if
any, and will not participate in the collective resolution.

4. Signature
Signature: ___________________________   Date: ________________
Printed Name: ________________________

Representative (if applicable)
Capacity/Title: _______________________
Authority Basis: ______________________

5. Submission Instructions
Send to: [RECIPIENT NAME AND ADDRESS / PORTAL URL]
Deadline: [ABSOLUTE DATE AND TIME WITH TIME ZONE]
Rule: [POSTMARK / RECEIPT]
Retain a copy and proof of submission (mailing receipt, confirmation).
```

## Pitfalls

- **Paraphrasing mandatory language** — use exact wording from the governing order or contract.
- **Missing identifiers** — omitting claim/account IDs is the most common rejection reason.
- **Relative deadlines** — always state absolute dates and times; never "within 30 days."
- **Scope creep** — do not add waivers, releases, or admissions beyond the opt-out election.
- **Signature mismatch** — if notarization/witnesses required, add those blocks and remove e-sign language.
- **Representative opt-outs** — minors or incapacitated persons require representative authority language.
- **Privacy** — confirm jurisdictional or program-specific rules before requesting sensitive data.