Free TAKE IT DOWN Act Removal Request Form template (text download)

Published Sep 29, 2026 · Last reviewed Sep 29, 2026 · by Agent Exchange

A request form with every element a valid TAKE IT DOWN Act request needs, for your site to host or to accept by email. Plain text, so it works as a web form, a PDF or an email template. Bracketed text marks what you fill in. Download the file or copy it; the generator version fills the brackets for you.

Removal request: intimate visual depiction published without consent
Submitted to: [Site name] ([https://example.com])
Send to: [contact email], or use the online form at [your request page URL]

1. Your name, or the name of the person you represent: ______________________
2. How we can reach you (email or phone): ______________________
3. You are:  [ ] the person depicted   [ ] a parent or guardian of the minor depicted   [ ] an authorized representative
4. Is the person depicted under 18?   [ ] yes   [ ] no
5. Where the content appears (paste every URL, one per line):
   ______________________
   ______________________
6. Brief description that lets us identify the image or video (do not attach it):
   ______________________
7. Good-faith statement: I have a good-faith belief that the identified content is an intimate visual depiction of me (or the person I represent) published without consent, and the information in this request is accurate.
   [ ] I agree
8. Signature (typed is acceptable): ______________________   Date: ______________

What happens next: [Site name] gives every request a ticket number, removes valid reports and any known identical copies within 48 hours of a complete request, and tells you the outcome. Requests involving a minor can also be made through NCMEC's Take It Down service (takeitdown.ncmec.org); adults can use StopNCII.org to prevent re-uploads on participating platforms. This process is provided under Section 3 of the TAKE IT DOWN Act, enforced by the Federal Trade Commission.

What a TAKE IT DOWN Act Removal Request Form must contain

The name of the person depicted, or of the person acting for them, and a way to reach them.
Relationship: the person depicted, a parent or guardian of a minor, or an authorized representative, with a flag when the person depicted is under 18.
Identification and location: every URL where the depiction appears and a description sufficient to identify it without attaching it.
A brief statement of good-faith belief that the depiction was published without consent.
A signature (typed counts as electronic) and the date; once received, a ticket number and the 48-hour deadline.

Primary sources: FTC: Complying with the TAKE IT DOWN Act. Informational, not legal advice.

The document is the notice; the desk is the process. The Takedown Desk hosts the request form this document points to: ticket numbers, the 48 hours deadline clock, a status page for the requester, and an exportable log for you. Base desk free during launch. Create the takedown desk

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