OPT OUT FORM
At our discretion we may share information solely about our transactions or experiences with you among persons related to us by common ownership or affiliated by corporate control (our corporate family). We may also, at our discretion, communicate other information to those same persons, unless you direct us in writing not to exchange this other information. We may disclose the following kinds of nonpublic personal information about you:
- Information we receive from you on applications or other forms, such as your name, address, social security number, assets, and income;
- Information about your transactions with us or our affiliates, such as your account balance and payment history;
- Information we receive from a consumer reporting agency, such as your creditworthiness and credit history.
By checking this box and returning this document to us, you are directing us
to not exchange information other than information relating solely to your transactions or experiences
with us.
Name (Please Print)
Social Security Number
Address
City 
State
Zip Code
Signature
Date
Print, complete, and mail to:
| 1ST SUMMIT BANCORP |
| of Johnstown, Inc. |
| Attn: Bookkeeping Dept. |
| P.O. Box 5480 |
| Johnstown, PA 15904 |
If you have previously indicated your preference, it remains in effect.
You do not need to restate your choice each year.