CCPA Request

I am making the request(s) below on behalf of myself
I am making the request(s) below as an authorized agent of another consumer

CCPA Consumer Request Form

As described further in our California Privacy Policy, as a California consumer you have the right to make certain requests about the personal information collected, used, or disclosed about you pursuant to CCPA and CPRA. SurePayroll is assisting businesses with these requests as a service provider. To exercise your rights, please complete the form below and press “submit” at the end of the form. The fields indicated by the asterisks are mandatory for submission.

In order to respond to your request, the CCPA requires us to verify the identity of the Consumer exercising their rights under CCPA. Please provide the following information and ensure it matches the data SurePayroll currently has in its systems:

Consumer First Name*

Consumer Last Name*

Consumer Phone Number*

Consumer E-mail*

Address Line 1*

Address Line 2

City*

Zip Code*

State*

Social Security Number*

Re-enter Social Security Number*

Date of Birth (YYYY-MM-DD)*

The following fields are optional and, if provided, may be used to assist SurePayroll in locating the Consumer:

Nickname or other name

Suffix

Consumer Request:

Consumer Request*

Consumer Location*

Email Address*

Mailing Address Line 1*

Mailing Address Line 2

Mailing City*

Mailing Zip Code*

Mailing State*

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If SurePayroll is unable to verify the Consumer’s identity based on the above information, or if the Consumer is not located based on the information provided, your request will be denied, and you will be provided with information on next steps. See our California Privacy Policy for more information.

I acknowledge that any false statement or other misrepresentation made on this form may subject me to civil and criminal penalties. I agree to indemnify and hold harmless SurePayroll, its affiliates and subsidiaries and each of their respective officers, directors, managers, members, employees and agents from any and all liability arising out of any fraudulent statements.

By submitting this form, I declare under penalties of perjury under the laws of the State of California that the foregoing information is true and correct.

CCPA Agent Request Form

If you are making the request(s) as an authorized agent of a Consumer, once request(s) received, you will receive an email with instructions on completing an Authorized Agent Form which will then be attached to the submittal record in order to proceed with processing the request. The request will not proceed with processing until a complete Authorized Agent Form is filed.

You Are:

Submitter First Name*

Submitter Last Name*

Submitter E-mail Address*

Re-Enter Submitter Email Address*

Initial Consumer Date of Request (YYYY-MM-DD)*