California Consumer Privacy Act Information Request

In order for Reliant to process your request, please complete this form, following all instructions. A separate form must be completed for each user.

Items marked with an asterisk * are required fields.

Requestor Information
Name*
First Last
Birth Date*
MM slash DD slash YYYY
Last 5 of Social Security Number*
Phone Number*
Physical Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
- Mailing Address (if different from above)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Does your request relate to personal data about yourself?*
- I am the consumer
- I am submitting request for the consumer
Please provide the above information in order to verify your identity. We may not be able to process your request if information is incomplete or inaccurate.
Declaration
By completing this form I declare that the details on this application are to the best of my knowledge correct. I understand that it may be a criminal offense to, or attempt to, obtain or disclose personal data unlawfully.*
- Yes
- No
Follow Up
After you submit this application you will be issued a reference number. Using this reference number you will be able to respond to follow up questions/comments and provide additional information.
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Requestor Information