Verifiable California Consumer Data Request

Subject's Legal Name

First Name (required)

Middle Name

Last Name (required)

E-mail Address (required)

Phone Number (required)

Phone Type (required) Select One Home Cell Business

Address (required)

City (required)

State (required) Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

ZIP

Driver's License Number

Issue State Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Date of Birth (required)

Social Security Number (Last 4 Digits) (required)

Is the subject a resident of California? (required) Select One Yes No

Subject is affiliated with Federated by a: (Select all that apply)

Preferred Method of Delivery (required) Select One E-mail US Mail

I am requesting Federated to:

• Categories of Personal Information Federated has collected about the consumer.
• Categories of sources from which Personal Information is collected.
• The business or commercial purpose for collecting Personal Information.
• Categories of third parties to whom Personal Information was disclosed for a business purpose.
• Categories of Personal Information that Federated disclosed for a business purpose about the consumer.
• Specific pieces of Personal Information that Federated has collected about the consumer.

*exceptions may apply

I am the California resident (“subject” above) who is requesting information about myself I am a natural person acting as the “Authorized Agent” requesting information on behalf of the California resident who is the subject of this request. I agree to comply with the requirements for the use of Authorized Agents as specified below. I am a business entity acting as the “Authorized Agent” requesting information on behalf of the California resident who is the subject of this request. I have been authorized by the subject of this request to act on his/her behalf. I agree to comply with the requirements below.

Entity Number assigned by the California Secretary of State (required)

IMPORTANT INFORMATION FOR AUTHORIZED AGENTS AND CONSUMERS USING AUTHORIZED AGENTS: If you, the Authorized Agent, have a valid power of attorney pursuant to California Probate Code sections 4121 to 4130 we will require you to provide a copy of that to us before we will provide any information or take any action requested pursuant to the request. If you do not have a valid power of attorney, Federated will require the Authorized Agent to provide (1) proof that the subject of this request/consumer gave the agent signed permission to submit the request, and (2) The consumer/subject must also directly confirm with Federated that they provided you, the Authorized Agent, permission to submit the request. Consumers and Authorized Agents should contact Federated at the toll-free-number 1-844-929-0147 or by e-mail at consumerdatarequest@fedins.com to provide information/documentation as required above.

By signing this document I hereby declare under penalty of perjury, pursuant to the laws of the United States of America and any applicable state laws, that I am the person making the request and that I have sufficient legal authority to make the request. I understand that falsifying any information could subject me to civil and criminal penalties.

Further, by typing your name or electronically signing this form you agree that your e-signature is legally binding and valid and serves as your original signature.

Signature (required)

Typed Name (required)

Business Name (if a business entity acting as an “Authorized Agent”)

Business Name (if a business entity acting as an “Authorized Agent”) (required)

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