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." A copy of this notification will be made available online.

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., 2018-11-17
Order
Date(s) of Discovery of Breach
E.g., 2018-11-17
Order
Date(s) Individual Notice Provided to Consumers
E.g., 2018-11-17
(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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