Request For Personal Data Records Reason for Request * Delete DataRequest DataBoth Delete Options * Delete Data, But Keep My AccountDelete Data, AND Delete My Account User's Name * User's Name First Name First Name Last Name Last Name Contact Number * The primary contact number of the user. User's Email Address The primary email address of the user. User's Date Of Birth * User's Address * User's Address User's Address User's Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Are these documents being requested by the user or an authorized requester? * User Authorized Requester Authorized Requestor's Information User's Full Name * User's Full Name User's first name User's first name User's last name User's last name Relationship To User * ParentChildSiblingSpousePartnerFriendColleagueAcquaintanceNeighborGrandparentGrandchildAunt/UncleNiece/NephewCousin Select your relationship to the user if you are not the user. Requestor's Contact Number * Requestor's Email Address * Data Record Details arrowup6 Email to Deliver Data * Please enter the email you would like the data delivered to. Please Confirm Email Address * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Authorization Authorization Statement * I, the undersigned, either as the user or as the authorized representative of the user, give permission for the user's data records to be shared with the specified person or organization. I acknowledge that these records may contain sensitive and confidential information. Signature * Captcha Submit If you are human, leave this field blank.
