North Carolina Security Breach Reporting Form Pursuant to the Identity Theft Protection Act of 2005 Name of Business or Government Agency Owning or Licensing Information Affected by the Breach: PLEASE SUBMIT FORM TO: Consumer Protection Division NC Attorney General’s Office 9001 Mail Service Center Raleigh, NC 27699-9001 Telephone: (919) 716-6000 Toll Free in NC: (877) 566-7226 FAX: (919) 716-6050 Address: Telephone: Fax: Email: Date Security Breach Reporting Form submitted: Date the Security Breach was discovered: Estimated number of affected individuals: Estimated number of NC residents affected: Name of business or government agency maintaining or possessing information that was the subject of the Security Breach, if the agency that experienced the Security Breach is not the same entity as the agency reporting the Security Breach (pursuant to N.C.G.S. § 75-65(b): Describe the circumstances surrounding the Security Breach and state whether the information breached was in electronic or paper format: Regarding electronic information breached, state whether the information breached or potentially breached If so, please describe the security was password protected or encrypted in some manner. measures protecting the information: Describe any measures taken to prevent a similar Security Breach from occurring in the future: Date affected NC residents were/will be notified: If there has been any delay in notifying affected NC residents, describe the circumstances surrounding the delay pursuant to N.C.G.S. § 75-65(a) and (c)): If the delay was pursuant to a request from law enforcement pursuant to N.C.G.S. § 75-65(c), please include the written request or the contemporaneous memorandum. How NC residents were/will be notified? (pursuant to N.C.G.S. § 75-65(e)) Please attach copy of the notice if in written form or a copy of any scripted notice if in telephonic form. written notice electronic notice (email) telephone notice substitute notice Signature: Contact Person, Title: Address: (if different from above) Telephone: Date: Fax: Email: American LegalNet, Inc. www.FormsWorkFlow.com