I understand that you need to be reasonably sure that I am making this request regarding my own information, or that I am authorized to make a request about someone else’s information. Therefore, I am providing the information below, which is accurate to the best of my knowledge, for purposes of allowing you to attempt to verify my request. I understand that you will use the verification data provided to cross-check information available in your existing records to the extent possible, and that you may contact me to request additional information and/or deny my request if the information provided is insufficient for purposes of verification. (Check appropriate box and provide associated verification information as applicable):
I understand that your response(s) to my request will be in writing and I authorize you to provide your response(s), send verification of receipt of my request, or contact me in connection with my request, using the following contact information and method(s) of delivery:
My Full Name
My Mailing Address
My Email Address
- I request information or action regarding my own personal information.
Last four digits of My Social Security Number
Account number of My Credit Report
- I request information or action regarding my minor child or a minor child for whom I serve as a legal guardian. By Checking this Box, I confirm that I am authorized to provide, and do hereby provide, consent for you to take action regarding and/or release to me information regarding the minor child.
Full Name of Minor
Address of Minor
Minor's Date of Birth
My Relationship to Minor (Parent or Legal Guardian)
Please upload proof of parentage or guardianship here. Acceptable forms of proof include a birth certificate or relevant court document establishing status with respect to the minor child. (max 5MB, PDF or JPG format)
- I make this request in my capacity as a designated and authorized individual seeking information or action regarding another person. By Checking this Box, I confirm that I am authorized to do so.
Full Name Whose Information is at Issue
Address of Person Whose Information is at Issue
Last four digits of the Social Security Number of the Person Whose Information is at Issue
Account Number of Credit Report of the Person Whose Information is at Issue
Please Upload a Signed Power of Attorney or proof of registration with the California Secretary of State as a Designated, Authorized Representative Here. (max 5MB, PDF or JPG format)
The nature of my request is as follows, and I understand that I am only permitted to make a verifiable consumer Request to Know or Request to Access regarding my data under the CCPA twice in any 12-month period. (Check appropriate box and provide associated information as applicable).
- Request to Know (Categories of Information). I would like to know for the past 12 months:
- Request to Know (Access to Specific Information). I would like to receive a copy of the Personal Information collected about me for the past 12 months. Unless otherwise noted here, I would like to receive copies of all such information. I am aware that you will not disclose a social security number, as that information is deemed too sensitive to provide. I am also aware that you are not required to disclose specific pieces of personal information to me, as opposed to categories, unless I provide to you a written declaration under penalty of perjury that I am the consumer whose personal information is the subject of this request.
Optional Restriction: I would only like to receive copies of the following Personal Information/Categories of Personal Information from your records:
Please Upload Declaration Under Penalty of Perjury Confirming you are the consumer whose personal information is at Issue (max 5MB, PDF or JPG format)
- Request to Delete. I would like the Personal Information collected about me to be deleted.
Optional Restriction: I would only like you to delete the following Personal Information/Categories of Personal Information from your records:
If you have any questions about this form or your CCPA rights, you may contact us at firstname.lastname@example.org or 1-877-440-0860.