Affidavit for Authorized Agent

Instructions: The AUTHORIZED AGENT must complete this form or provide documentation establishing registration with the California Secretary of State.

Affidavit of Identity

1. I, _____________________________________(Full Name: First, Middle Initial, Last) do hereby declare and certify that I reside at ____________________________________ (Street Address) in ______________________________________ (City/Town) in the State of California
2. I have been duly authorized by _______________________________ (name of consumer) to make requests on his or her behalf, pursuant to the California Consumer Privacy Act and/or other applicable data protection law.
3. _______________________ (consumer name) is the registered customer for telephone number _________________________ and for the following email addresses: ____________________________________________________________________
4. I submitted a Consumer Privacy Request on __________________ (date of request) in order to obtain information, deletion or opt-out rights on behalf of _______________________________ (consumer’s name) and at his or her direction. I swear or affirm, under penalty of perjury, that this statement is true and correct.
   ______________________________ Authorized Agent
   Subscribed and Sworn before me this day: _______________________________ (notary public)

Consumer Affidavit to Authorize Agent

1. I, _____________________________________(Full Name: First, Middle Initial, Last) do hereby declare and certify that I reside at ____________________________________ (Street Address) in ______________________________________ (City/Town) in the State of California
2. I am the registered customer for telephone number _________________________ and for the following email addresses: ____________________________________________________________________
3. I authorize ___________________________________ (Representative Full Name) of ____________________________________ (Street Address) in ______________________________________ (City/Town) in the State of _____________________ (State) to submit a Consumer Privacy Request on ____________________ (date of request) on my behalf in order to obtain information and/or to request deletion or opt-out rights for me under the California Consumer Privacy Act. I swear or affirm, under penalty of perjury, that this statement is true and correct.
   __________________________________ (Consumer Signature)
   Subscribed and Sworn before me this day: __________________________________ (notary public)