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LA Database Security Breach Reporting Form

Reporting Entity’s Information:

Submitter’s Information:

(or Firm)

Details of the Breach:

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


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):

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 )