New York State Attorney General


New York State Security Breach Reporting Form

Pursuant to the Information Security Breach and Notification Act

(General Business Law §899-aa)




Entity Information
Name and address of entity that owns or licenses the computerized data subject to the breach





Breach Details
Description of breach - Select all that apply*
 







 
Information acquired in combination with name or other personal identifier - Select all that apply *
 


number, in combination with the security code, password,
or PIN for the account)






Number of persons affected
 
 
Do you believe that this security breach was part of a larger breach that likely affected other organizations? *
*

If the number of NYS residents exceeds 5,000, have the consumer reporting agencies been notified?

Dates of breach
 
Breach occurred: *
                       
              * mm/dd/yyyy                * mm/dd/yyyy  * mm/dd/yyyy





Other information
   * mm/dd/yyyy
 
Manner of notification to affected persons - Select all that apply*




 
Note: Please do not upload password protected files.
 
 
 
 
 
 
 
 
 
 
Identity theft protection service offered: *




Submitted By:



  *###-###-####
 
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