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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