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.
More information
  • 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., 2017-08-19
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Order
Date(s) of Discovery of Breach
E.g., 2017-08-19
Order
Date(s) Individual Notice Provided to Consumers
E.g., 2017-08-19
(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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