LA Database Security Breach Reporting Form

Reporting Entity’s Information:

Name:

Address:

City:

State:

Zip Code:

Phone:

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Submitter’s Information:

Name:

Address:

City:

State:

Zip Code:

Phone:

Email:

Company: (or Firm)

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Details of the Breach:

Initial Breach Notice
Supplemental Breach Notice

Approximate Number of Louisiana Residents Affected by the Breach (If known):

LA Residents:

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Dates:

Date Breach Discovered:

Date Consumers Were Notified:

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Information Involved in the Breach

(Please select all that apply:)
Social Security Numbers
Driver’s License / State ID Numbers
Financial Information (e.g. account, credit or debit card numbers)
Passport Numbers
Biometric Data
Other (specify):

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Notification to Affected Individuals:

Written Notification
Electronic Notification
Substitute Notification:



Upload a Cover Letter Here:


Uplaod a Breach Notification Sample here:

( Files must be under 1MB and one of the following types: .jpg, .png, .pdf )


Submit