Utility Customer Data Breach Claim Form

Full Name

First NameLast Name

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Current Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Utility Account Reference Number

Type of Data Believed to Be Affected

Date You Became Aware of the Breach

Date

How did you learn about the data breach?

Other

Describe the impact the breach has had on you

Briefly describe your claim related to the breach