NEW YORK STATE SECURITY BREACH REPORTING FORM Pursuant to the Information Security Breach and Notification Act (State Technology Law §208) Name and address of Entity that owns or licenses the computerized data that was subject to the breach: _______________________________________________________________________________________________ Street Address: _____________________________________________________________________________ City: ______________________________________ State: ________ Zip Code: _____________________ Submitted by: _________________________ Title: __________________________ Dated: _______________ Firm Name (if other than entity): __________________________________________________________________ Telephone: __________________________________ Email: _____________________________________ Relationship to Entity whose information was compromised: _____________________________________ ___ Type of Organization (please select one): [ ] Governmental Entity in New York State; [ ] Other Governmental Entity; [ ] Educational; [ ]Health Care; [ ]Financial Services; [ ]Other Commercial; [ ]Notforprofit Number of Persons Affected: Total (Including NYS residents):_____________ NYS Residents:_______________ If the number of NYS residents exceeds 5,000, have the consumer reporting agencies been notified? [ ] Yes; [ ] No. Dates: Breach Occurred:___________ Breach Discovered:___________ Consumer Notification:__________ ___ Description of Breach (please select all that apply): [ ]Loss or theft of device or media (e.g., computer, laptop, external hard drive, thumb drive, CD, tape); [ ]Internal system breach; [ ]Insider wrongdoing; [ ]External system breach (e.g., hacking); [ ]Inadvertent disclosure; [ ]Other (specify):_________________________________________________________________________________ Information Acquired: Name or other personal identifier in combination with (please select all that apply): [ ]Social Security Number [ ]Drivers license number or nondriver identification card number [ ]Financial account number or credit or debit card number, in combination with the security code, access code, password, or PIN for the account Manner of Notification to Affected Persons ATTACH A COPY OF THE TEMPLATE OF THE NOTICE TO AFFECTED NYS RESIDENTS: [ ] Written; [ ] Electronic; [ ] Telephone; [ ] Substitute notice. List dates of any previous (within 12 months) breach notifications: _____________________________________ Identify Theft Protection Service Offered: [ ] Yes; [ ] No. Duration: ____ _____ Provider: ___________________________________________________________ Brief Description of Service: ____ _______________________________________________________ Rev 6/17/2013 American LegalNet, Inc. www.FormsWorkFlow.com PLEASE COMPLETE AND SUBMIT THIS FORM TO EACH OF THE THREE STATE AGENCIES LISTED BELOW: Fax or Email this form to: New York State Attorney General's Office SECURITY BREACH NOTIFICATION Consumer Frauds & Protection Bureau 120 Broadway, 3rd Floor New York, NY 10271 Fax: 212-416-6003 Email: breach.security@ag.ny.gov New York State Office of Information Technology Services Enterprise Information Security Office SECURITY BREACH NOTIFICATION 1220 Washington Avenue State Office Campus Building 7A, 4th Floor Albany, NY 12242 Fax: 518-322-4976 Email: eiso@its.ny.gov New York State Department of State Division of Consumer Protection Attention: Director of the Division of Consumer Protection SECURITY BREACH NOTIFICATION 99 Washington Avenue, Suite 650 Albany, NY 12231 Fax: 518-473-9055 Email: security_breach_notification@dos.ny.gov Rev 6/17/2013 American LegalNet, Inc. www.FormsWorkFlow.com