VERMONT STATE SECURITY BREACH REPORTING FORM

Pursuant to the Vermont Security Breach Notice Act
(9 V.S.A. §§ 2430, 2435)

Firm Name (if other then entity)

Relationship to Entity whose information was compromised

Please note that the discovery date is NOT the date than an investigation is completed, it is the earliest date than an entity became aware of, or had a reasonable belief of, unathorized activity.

Consumer Notification(s)

List dates of any previous (within 12 months) breach notifications

Name and address of Entity that owns or licenses the computerized data that was subject to the breach

Submitted By

Type of Organization

Number of People Affected

Dates

Description of Breach

Information Acquired: Name or other personal identified in combination with

Manner of Notification to Affected People

Identify Theft Protection Service Offered

Contact Information