NEW YORK STATE SECURITY BREACH REPORTING FORM Pursuant to the Information Security Breach and Notification Act (General Business Law §899-aa) 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; or [ ]Not-for-profit. 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 [ ]Driver's license number or non-driver 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: ____ _______________________________________________________ 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 Division of State Police SECURITY BREACH NOTIFICATION New York State Intelligence Center 31 Tech Valley Drive, Second Floor East Greenbush, NY 12061 Fax: 518-786-9398 Email: risk@nysic.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, New York 12231 Fax: (518) 473-9055 Email: security_breach_notification@dos.ny.gov American LegalNet, Inc. www.FormsWorkFlow.com