California Privacy Law Request

All fields with an (*) are mandatory

REQUEST FOR INFORMATION COLLECTED | REQUEST FOR IDENTIFICATION | REQUEST FOR DELETION OF INFORMATION COLLECTED BY RAUSCH STURM LLP (CALIFORNIA RESIDENTS ONLY)

First Name*

Last Name*

Street Address*

Address Line 2

City*

State*

Zip Code*

Phone Number*

Email Address*

Account Number (if known)

Last 4 Digits of Social Security*

Date of Birth*

Request

Pursuant to the California Privacy Rights Act, I hereby declare under penalty of perjury that the information provided above is true and correct and that I (the individual described above) am the individual that is providing the information above.

I hereby request deletion of the personal information about me that Rausch Sturm has collected from me.

I hereby request that Rausch Sturm correct the following inaccurate personal information about me.

I hereby request to know what personal information Rausch Sturm has collected about me.

I hereby request to know what personal information Rausch Sturm has sold or shared about me.

I hereby request that Rausch Sturm not sell or share my Personal Information.

I hereby request the Rausch Sturm limit the use and disclosure of Sensitive Personal Information.

Today's Date*

E-Signature*

By submitting this form I am authorizing Rausch Sturm LLP to contact me using the phone numbers or email address supplied.