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):

REQUESTOR'S CONTACT INFORMATION

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:

VERIFICATION INFORMATION

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):

NATURE OF REQUEST

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).

I would like to know for the past 12 months:

  • The categories of Personal Information you have collected about me;
  • The categories of sources from which that Personal Information has been collected;
  • The categories of Personal Information collected about me that have been sold or disclosed to others for a business purpose; and
  • The categories of Third Parties to whom the Personal Information collected about me has been sold or disclosed for a business purpose.

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.

If you have any questions about this form or your CCPA rights, you may contact us at privacy@resurgencelegal.com or 1-877-440-0860.

Our Privacy Policy is also available online, at https://resurgencelegal.com/privacy.