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

[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.