California Consumer Request Form – Authorized Person Requesting on Behalf of Consumer

SECTION 1. CONSUMER'S INFORMATION

Please provide consumer's information. Fields with an asterisk ("*") are required in order to submit the form.
First Name*

Last Name*

Common Aliases
(including previous surnames, maiden names, nicknames)

Any business or fictitious business name associated with you

Phone number*
(Please use the XXX-XXX-XXXX phone number format)

Email*

Street Address*

City*

State*
Must be California address to be eligible base on the California Consumer Privacy Act (CCPA)

Zip code*

Is the consumer an applicant for employment or a current or former employee of Optio Solutions?*

SECTION 2. CATEGORIES OF INFORMATION YOU ARE REQUESTING
If you are requesting categories of personal information on behalf of a consumer, you must complete this section.
To help us understand and respond to your request quickly and efficiently, please provide as much detail as possible about the consumer’s personal information you are requesting to know or delete in the box below. Please include names, dates and time frames, descriptions, services, documents, or any other information to help us locate the consumer’s personal information.
Information you are requesting*

We may contact you if the scope of your request is unclear or does not provide sufficient information for us to conduct a search (for example, if you request “all information about me”). We will begin processing your request as soon as we have verified your identity and have all the information we need to locate your personal information.
SECTION 3. SPECIFIC PIECES OF INFORMATION YOU ARE REQUESTING ACCESS TO OR REQUESTING BE DELETED
If you are requesting specific pieces of personal information or deletion of personal information on behalf of a consumer, you must complete this section.
We require proof of the consumer’s identity before we can respond to the request. We accept a photocopy or a scanned image of a Driver’s license or other government-issued identification, which is requested under Section 4. If the consumer does not have this form of identity, please contact us to discuss whether a different proof of identity may be submitted.
Specific pieces of information you request access to and detailed description

Information you request to be deleted and detailed description

DECLARATION UNDER PENALTY OF PERJURY
I declare under penalty of perjury under the laws of the State of California, that the information provided on this form is correct.
By entering your full name and today's date, you are formally agreeing to the above statement*

Today's Date*

SECTION 4. VERIFICATION OF IDENTITY AND AUTHORIZATION
We require proof of your authorization to act on the consumer’s behalf, and verification of your identity unless you are submitting power of attorney pursuant to CA Probate Code §4000 et seq. We accept a copy of the following as proof of your legal authority to act on the consumer’s behalf and verification of your identity:
- A certified copy of a power of attorney.
- A written consent signed by the consumer, with a copy of your Driver’s license or other state-issued identification.
- Evidence of parental responsibility, with a copy of your Driver’s license or other state-issued identification.
If we do not receive proof of your authority or are unable to verify your identity (where required) or the identity of the consumer on whose behalf the request is being made, we will deny the request and inform you of the reason for the denial.
Your first name*

Your last name*

Your street address*

Your city*

Your state*

Your zip code*

Your phone number*

Your email address*

What is your relationship to the consumer (for example, attorney, other adviser, parent, cargiver)?*

Do you have legal authority to request this information on behalf of the consumer?*

Submit copy of documentation of legal authority to act on behalf of the consumer*
If submitting form by mail, please include a photocopy of a Driver's License or other state-issued identification.

Submit photocopy of your Driver’s License or state-issued identification (if no power of attorney)
If submitting form by mail, please include a photocopy of a Driver's License or other state-issued identification.

Submit photocopy of consumer’s Driver’s License or state-issued identification (if requesting specific pieces of personal information or deletion of personal information of the consumer)
If submitting form by mail, please include a photocopy of a Driver's License or other state-issued identification.

By providing us your mailing address, telephone number (including cellular numbers), or email address, you consent to CrossCheck contacting you by any such method.
By entering your full name and today's date, you are formally agreeing to the above statements.*

Today's date*