Please complete the information below to request suppression of your publically available information through the NMLS Consumer Access website. This request can only be made by the individual for whom the information is being suppressed.
  
•	Indicates Mandatory Information

Individual Information		
•	NMLS Unique ID:		
		
•	Legal First Name:		
      Middle Name:		
•	Legal Last Name:		
		
•	Company Affiliated with: 		
		
•	Company NMLS Unique ID:		
		
•	Jurisdictions where licensed: 		
		
Type of Suppression Requested:		
•	Full Suppression (The entire record is suppressed from NMLS Consumer Access)	•	Partial Suppression (A portion of the record is suppressed from NMLS Consumer Access)	
If requesting Partial Suppression, indicate what should be suppressed below:	
•	Employment Information	•	Office Locations	•	Phone, fax, prior legal names, prior other names	
•	Reason for Suppression:		

Required Legal Documentation Attached (indicate all relevant):	
	
•	Restraining Order	•	Police Report	•	Affidavit*	•	Other	
                                   
* If only an affidavit is submitted, additional explanation is required to indicate why a Restraining Order or Police Report is not attached. 
 
Under penalties of perjury, I declare that the information contained in this form and all accompanying documentation is true, correct, and complete.  

Signature _________________________________________       Date __________________