Washington State

Office of the Attorney General

Attorney General

Bob Ferguson

  1. Home
  2. Serve The People
  3. Safeguarding Consumers
  4. Consumer Issues A-Z
  5. Identity Theft & Privacy
  6. Data Breach Notifications
  7. Data Breach Notification Form

Data Breach Notification Form

IMPORTANT: Please do not use this form to provide updates to a previously submitted notice. Please send all updates to SecurityBreach@atg.wa.gov, and include the date of submission of the original notice you provided. Thank you.
* Required Information
1 Entity Details
*
(The name of the company/agency/entity that experienced data-breach)



*
*

WA
*
*
*
2 Breach Detail
*
RadDatePicker
RadDatePicker
Open the calendar popup.
*
RadDatePicker
RadDatePicker
Open the calendar popup.
*
RadDatePicker
RadDatePicker
Open the calendar popup.

RadDatePicker
RadDatePicker
Open the calendar popup.

RadDatePicker
RadDatePicker
Open the calendar popup.

*
*
*

*
3 Notice to Washington Residents

*
RadDatePicker
RadDatePicker
Open the calendar popup.
*
*

Upload Attachments You may upload 5 files with a total file size limit of 20 megabytes.

Please provide the following documents as well as any supporting documentation (PDF Only):



  • *


4 Contact Information
*
*

*
*
*
*
WA
*
*
*
*
A confirmation email containing a copy of your completed submission will be emailed to the address provided.
5 Public Record Disclosure and Signature
* I acknowledge that the information provided, including the attachments, once submitted will be posted on the Attorney General Office’s public facing website and may constitute a public record.
I declare, under penalty of perjury under the laws of the State of Washington, that the information contained in this complaint is true and accurate, and that any documents attached are true and accurate copies of the originals.
*
*
RadDatePicker
RadDatePicker
Open the calendar popup.
*
*