Submit Data Security Breach

State

Date(s) of Breach (if known)	Order
	Date(s) of Breach (if known) Date	Weight for row 1

Date(s) of Discovery of Breach	Order
	Date(s) of Discovery of Breach Date	Weight for row 1

Date(s) Individual Notice Provided to Consumers	Order
	Date(s) Individual Notice Provided to Consumers Date	Weight for row 1

Type of Entity

Is the organization a small business, according to the Small Business Administraton? *

Yes

No

Unsure

(See the Small Business Administration’s standards for defining a “small business”: www.sba.gov/sites/default/files/files/Size_Standards_Table.pdf.)

Location of Breached Information

Vertical Tabs