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Submit Data Security Breach

This submission is required by California Civil Code s. 1798.29(e); California Civil Code s. 1798.82(f)

Note: This form is only for use by businesses and state agencies, which are required to submit a sample notice if they experience a breach of personal information involving more than 500 California residents.
If you are a consumer who wishes to file a complaint, please use our online complaint form.

* denotes required field.

SECTION 1 - ATTACH SECURITY BREACH NOTIFICATION SAMPLE
Sample of Electronic Notice
Click browse button to select file and then click upload to attach the file.
Files must be less than 256 MB.
Allowed file types: pdf.
Order
Date(s) of Breach (if known)
E.g., 2014-04-23
CAPTCHA
This question is for testing whether you are a human visitor and to prevent automated spam submissions.
Order
Date(s) of Discovery of Breach
E.g., 2014-04-23
Order
Date(s) Individual Notice Provided to Consumers
E.g., 2014-04-23
("Press Ctrl for Multiple Selections") If selecting an "Other" category, please describe the information in detail in the Description section below.
Please include the location of the breach, a description of how the breach occurred, and any additional information regarding the type of breach, type of media, and type of protected involved in the breach.
("Press Ctrl for Multiple Selections")
SECTION 2 - INFORMATION FOR LAW ENFORCEMENT PURPOSES
The information provided in SECTION 2 is for DOJ use only.

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