CCPA form Verified Consumer Request Form To process Your Verified Consumer Request, we need some basic information from You. We will only use personal information provided to verify Your identity or authority to make the request, to locate the information within our systems and respond to Your request. We cannot respond to Your request if we cannot verify Your identity or authority to make the request and confirm that the personal information relates to You. For more information, please go to Privacy Notice and Disclosure for California Residents.SECTION 1: ConsumerFull Name Email Address Used with Co-Parenter, LLC(Required) (note this address will also be used for correspondence relating to this request)Phone number used with Co-Parenter, LLCInsert text here...Please provide any additional information that might be helpful in fulfilling Your request regarding how you have engaged with Co-Parenter, LLC. For example, “I purchased a product last month.” SECTION 2: Are you the Consumer who is the subject of this Request? YES, I am the Consumer that is the subject of this Request. NO, I am the Authorized Agent acting on behalf of the Consumer that is the subject of this Request. Please go to section 3. SECTION 3: Details of Authorized Agent If this request is on the behalf of the Consumer, upload either a copy of a power of attorney provided by the Consumer pursuant to Probate Code sections 4121 to 4130 or proof of signed permission along with a copy of the Authorized Agent’s ID. If a power of attorney is not provided, the Consumer will be required to confirm with us directly that they provided permission to submit the request.Upload FileMax. file size: 120 MB.SECTION 4: Nature of RequestPlease select all desired options:Please select all desired options: Specific pieces of personal information that Co-Parenter, LLC has collected about You.* *This request requires filling out Section 5 to specify the method you want to receive the specific pieces of information. Please also complete the declaration in Section 6 to finalize this request. Deletion of Your personal information.* *Please complete the declaration in Section 6 to finalize this request. Categories of Consumer personal information Co-Parenter, LLC has collected about You. Categories of sources from which Your personal information is collected. Categories of Your personal information that Co-Parenter, LLC sold or disclosed for a business purpose. Categories of third parties to whom Your personal information was sold or disclosed for a business purpose. The business or commercial purpose for collecting or selling Your personal information SECTION 5: Delivery OptionsThe e-mail address you provided in Section 1 will be used for correspondence relating to this request. If you made a request to know specific pieces of information you can receive the information electronically or by mail. If you elect to receive the information by mail please provide your mailing address. Mail Delivery – provide mailing address Electronic Delivery Mailing addressSECTION 6: DeclarationThe following CCPA requests require you to submit a signed declaration under penalty of perjury that you are the consumer whose personal information is the subject of this request. Right to Know – Specific Pieces of Personal Information Deletion Request Please complete the below declaration as required so that we may fulfill your request made pursuant to CCPA.Declaration in Support of Verified Consumer RequestI. Choose Request Type: Right to Know – Specific Pieces of Personal Information Deletion Request I acknowledge that I am a California resident and the person making the request noted above, under the California Consumer Privacy Act. I acknowledge that I am making this request in good faith on behalf of myself. I certify and declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Declarant Signature Print Name Date MM slash DD slash YYYY Complete this form online or click here to download the form to submit via mail or email.File Drop files here or Select files Max. file size: 120 MB. If You choose not to upload this declaration directly You can send it to either:Mailing Address: 2317 3rd Avenue North Suite 101 Birmingham, Alabama 35203Email Address: support@coparenter.comRead our Privacy Notice and Disclosure for California Residents
