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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 and local government 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.

SECTION 1 - ATTACH SECURITY BREACH NOTIFICATION SAMPLE
Sample of Notice
California Civil Code s. 1798.29(e) and s. 1798.82(f) provide that “…A single sample copy of a security breach notification shall not be deemed to be within subdivision (f) of Section 6254 of the Government Code.

Click browse button to select file and then click upload to attach the file.
Files must be less than 1 GB.
Allowed file types: pdf.
SECTION 2 - INFORMATION FOR LAW ENFORCEMENT PURPOSES
The information provided in SECTION 2 is for DOJ use.
Order
Date(s) of Breach (if known)
E.g., 2017-06-28
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., 2017-06-28
Order
Date(s) Individual Notice Provided to Consumers
E.g., 2017-06-28
("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 information involved in the breach.
("Press Ctrl for Multiple Selections")
(See the Small Business Administration’s standards for defining a “small business”: www.sba.gov/sites/default/files/files/Size_Standards_Table.pdf.)

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