Data Breach Notification Form

Pursuant to A.R.S. § 18-552(B)(2)(b), a person that owns or licenses computerized data that experiences a system security breach may provide notice of the data breach to the Arizona Attorney General using this form. Defined terms (e.g., Person, Breach, Security Incident, Personal Information, Nationwide Consumer Reporting Agency, etc.) that are used below shall have the meanings set forth in A.R.S. § 18-551.

Notifications provided to the Attorney General using this form are confidential pursuant to A.R.S. § 44-1525 and are exempt from disclosure under A.R.S. § 39-101 et seq., but may be used by the Attorney General to investigate the data breach or any related incidents or conduct.

Name of Person that experienced the Breach:

Name and contact of legal counsel (if applicable):

Date of Security Incident that prompted an investigation:

Date investigation was launched:

Date of determination that a Breach occurred:

Approximate date(s) of Breach:

Approximate date(s) of Breach:
Approximate date(s) of Breach:

Description of Personal Information included in the Breach:

Number of Arizona consumers affected:

Were affected Arizona consumers notified of the Breach? If so, provide the date(s) and the method of notification.

Provide a sample notification letter (if applicable).

Upload requirements

Were the three largest Nationwide Consumer Reporting Agencies notified? If so, provide the date(s).

Additional Information (optional):

Name

Company

Phone

Signature

Sign above

Date