Privacy Request Intake Form

Important Privacy Information

Your privacy is very important to us. If you would like to appeal the response you received to your consumer request, please complete the form below. All fields marked with an asterisk(*) are required so we can properly verify your identity.

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The requester is a resident of:

Previous Request ID:

Information of the Minor for whom the request is being submitted

Please complete the following fields with the information of the person for whom you are making the request; this information will only be used to fulfill this request. If this is an Access My Information request, please be prepared to upload one of the following documents for verification: Certified Birth Certificate, Court Order of Guardianship or Conservatorship, Letters of Guardianship or Conservatorship.

Information of the Adult for whom the request is being submitted

Please complete the following fields with the information of the person for whom you are making the request; this information will only be used to fulfill this request. If this is an Access My Information request, please be prepared to upload one of the following documents for verification: Court Order of Guardianship or Conservatorship, Letters of Guardianship or Conservatorship, or Power of Attorney provided pursuant to California Probate Code sections 4000 to 4465.

Guidance:

The Previous Request ID is found on your previously submitted request to access, delete or correct your personal information and must be provided to proceed with this request. Please provide context to your request in the Detailed Reason for Appeal field.

Request Type:

Access My Information

Delete My Information

Correct My Information

Person Information

Detailed Reason for Appeal:

First Name:

Last Name:

Email:

Confirm Email: Email not matched

Verification

I certify that the information provided in this request is correct and accurate, and I am the individual whose personal information is the subject of this request, or I am authorized to act on such individual's behalf.