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I acknowledge that I am a resident of the state indicated above and the person making the request noted. I acknowledge that I am making this request in good faith on behalf of myself
I CERTIFY AND DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF MY RESIDENT STATE INDICATED ABOVE AND THAT THE FOREGOING INFORMATION IS TRUE AND CORRECT AND THAT I AM THE CONSUMER WHOSE PERSONAL INFORMATION IS THE SUBJECT OF THE REQUEST.
If this request is being made on behalf of a consumer by an authorized agent, please send a copy of the signed permission to do so or provide the authorized agent power of attorney. This documentation can be mailed to Goosehead at 1500 Solana Boulevard, Ste. 4500, Westlake, TX 76262 or submitted via email to email@example.com.