NEWYORKSTATESECURITYBREACHREPORTINGFORM

PursuanttotheInformationSecurityBreachandNotificationAct
(GeneralBusinessLaw899aa)

NameandaddressofEntitythatownsorlicensesthecomputerizeddatathatwassubjecttothebreach:
_______________________________________________________________________________________________
StreetAddress: _____________________________________________________________________________
City:______________________________________ State:________
ZipCode:_____________________

Submittedby: _________________________Title:__________________________Dated:_______________
FirmName(ifotherthanentity):
__________________________________________________________________
Telephone:__________________________________
Email:_____________________________________
RelationshiptoEntitywhoseinformationwascompromised:________________________________________

TypeofOrganization(pleaseselectone):[] Governmental EntityinNewYork State;[]OtherGovernmentalEntity;

[]Educational;[]HealthCare;[]FinancialServices;[]OtherCommercial;or[]Notforprofit.

NumberofPersonsAffected:
Total(IncludingNYSresidents):_____________NYSResidents:_______________
IfthenumberofNYSresidentsexceeds5,000,havetheconsumerreportingagenciesbeennotified?[]Yes[]No

Dates: BreachOccurred:___________BreachDiscovered:___________ ConsumerNotification:__________ ___

DescriptionofBreach(pleaseselectallthatapply):
[]Lossortheftofdeviceormedia(e.g.,computer,laptop,externalharddrive,thumbdrive,CD,tape);
[]Internalsystembreach;[]Insiderwrongdoing;[]Externalsystembreach(e.g.,hacking);
[]Inadvertentdisclosure;[]Otherspecify):________________________________________________________________

InformationAcquired:Nameorotherpersonalidentifierincombinationwith(pleaseselectallthatapply):
[]SocialSecurityNumber
[]Driverslicensenumberornondriveridentificationcardnumber
[]Financialaccountnumberorcreditordebitcardnumber,incombinationwiththesecuritycode,accesscode,
password,orPINfortheaccount

MannerofNotificationtoAffectedPersons ATTACHACOPYOFTHETEMPLATEOFTHENOTICETO
AFFECTEDNYSRESIDENTS:
[]Written[]Electronic[]Telephone[]Substitutenotice
Listdatesofanyprevious(within12months)breachnotifications:_____________________________________
IdentifyTheftProtectionServiceOffered:[]Yes[]No
Duration:_________Provider:___________________________________________________________
BriefDescriptionofService:___________________________________________________________

Rev 6/20/2013


PLEASECOMPLETEANDSUBMITTHISFORMTO
EACHOFTHETHREESTATEAGENCIESLISTEDBELOW:

FaxorEmailthisformto:
NewYorkStateAttorneyGeneralsOffice
SECURITYBREACHNOTIFICATION
ConsumerFrauds&ProtectionBureau
120Broadway3rdFloor
NewYork,NY10271
Fax:2124166003
Email:breach.security@ag.ny.gov

NewYorkStateDivisionofStatePolice
SECURITYBREACHNOTIFICATION
NewYorkStateIntelligenceCenter
630ColumbiaStreetExt
Latham,NY12110
Fax:5187869398
Email:risk@nysic.ny.gov

NewYorkStateDepartmentofStateDivisionofConsumerProtection
Attention:DirectoroftheDivisionofConsumerProtection
SECURITYBREACHNOTIFICATION
99WashingtonAvenue,Suite650
Albany,NewYork12231
Fax:(518)4739055
Email:security_breach_notification@dos.ny.gov

Rev 6/20/2013