CCPA Privacy Rights Request Form

CCPA Privacy Rights Request Form

If you are a California resident, you have certain rights under the California Consumer Privacy Act (“CCPA”). At Political Data Intelligence LLC, we are committed to respecting and protecting your privacy. If you would like to exercise any of your privacy rights, please fill out the form below. Required fields are marked with an asterisk.* We will contact you at the email or phone number listed below if we have questions regarding your request.
Name*

First NameLast Name
E-mail*
example@example.com
Phone Number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this request for yourself or on behalf of someone else?

MyselfOn behalf of someone else (“Authorized Agent”)
Relationship to California Resident:
Select all that apply:

Request for disclosure (tell me about my data)Request for access (give me my data)Request for deletion (delete my data)Request for correction (correct my inaccurate data)
If you are an authorized agent of a California resident and are making this request on his or her behalf, you will be required to provide a copy of the California resident’s written authorization (for example a power of attorney) showing that you have been granted the authority to submit a consumer rights request on behalf of the California resident. You will be contacted at either the email address or mailing address you provided above, in order to request a copy of this document for verification purposes.

To the extent that the written authorization provided to us is insufficient, we will contact you for further verification at the contact information you provided above. We may additionally contact the California resident in order to verify his or her identity, and to confirm your authority to make a consumer rights request on his or her behalf, prior to responding directly to you.
Are you the California Resident?

YesNo
ACKNOWLEDGEMENT*

I understand that I may make a verifiable privacy request twice within a twelve (12) month period. If I have submitted a request for deletion, I understand that, while I have the right to request deletion of my personal information, PDI may be able to retain some or all of the personal information for a variety of ‎reasons, such as to comply with a legal obligation.‎ I further understand that PDI will respond to my request as necessary using the information I provided above.
For more information on your rights under the CCPA, please see our privacy policy.
Proof of California Residency*

Examples: Recent utility bill showing a California service address, Current residential lease or rental agreement (Address page only) Property tax bill or homeowner association statement, California voter registration confirmation.
Cancelof
Verification Notice:

This document will be used solely to verify California residency in connection with your privacy request.

Please redact any information not necessary to confirm residency, including identification numbers, photographs, financial details, or account numbers.

Any document submitted for verification will be securely deleted or destroyed promptly after verification is completed and will not be retained, shared, or used for any other purpose.

We will respond within the time required by applicable law.
Please verify that you are human*
Should be Empty: