Completing this form will help us to address your request quickly and effectively. You can also contact us at (855) 526-6737.
Under the State Privacy Laws, you may be permitted to use an authorized agent to make a request on your behalf. However, we may need to verify your authorized agent’s identity and authority to act on your behalf. We may require a copy of a valid power of attorney given to your authorized agent pursuant to applicable law. If you have not provided your agent with such a power of attorney, we may ask you to take additional steps permitted by law to verify that your request is authorized, such as by providing your agent with written and signed permission to exercise your rights on your behalf, the information we request to verify your identity, and confirmation that you have given the authorized agent permission to submit the request.
If you have any questions about this form or your request, please contact firstname.lastname@example.org.
1. Information About you
Please provide the following information. If you have an account number or other reference number, please provide it.
We may need to verify your identity in order to process your request and we may also need to confirm your residency. To verify your identity, we may require government identification, a declaration under penalty of perjury, or other information, where permitted by law.
2. Whose personal data are you requesting?
Please provide the following information. If you are making this request on behalf of someone else, we will need the additional information in Section 2.2 before we can respond to your request.
2.2 If you are not requesting access to your own personal data, please provide the following information about the person on whose behalf you are making this request:
For security reasons, we may not be able to respond to a request until we are able to verify the identity of the person you are making the request for, as well as confirming that you are authorized to request such information on the individual’s behalf.
Please complete the fields below: