Submit a CCPA Request

Verified Consumer Request Form

To process Your Verified Consumer Request, we need some basic information from You. We will only use personal information provided to verify Your identity or authority to make the request, to locate the information within our systems and respond to Your request. We cannot respond to Your request if we cannot verify Your identity or authority to make the request and confirm that the personal information relates to You.

For more information, please go to Privacy Notice and Disclosure for California Residents.

  • Section 1: Consumer

  • (note this address will also be used for correspondence relating to this request)
  • Please provide any information that might be helpful in fulfilling your request regarding how you have engaged with RELIANCE PARTNERS. For example, “I purchased a product last month” or “I typically shop at the [insert location] store”
  • SECTION 2: Are You The Consumer

  • SECTION 3: Details of Authorized Agent

  • If this request is on the behalf of the Consumer, send either a copy of a power of attorney provided by the Consumer pursuant to Probate Code sections 4121 to 4130 or proof of signed permission along with a copy of the Authorized Agent’s ID in the document field below. If a power of attorney is not provided, the Consumer will be required to confirm with us directly that they provided permission to submit the request.
  • Drop files here
    Max. file size: 10 MB, Max. files: 3.
    • SECTION 4: Nature of Request

      * This request requires filling out Section 5 to specify the method you want to receive the specific pieces of information. Please also complete the declaration in Section 6 to complete this request.
      ** Please complete the declaration in Section 6 to complete this request.
    • SECTION 5: Delivery Options

    • The e-mail address you provided in Section 1 will be used for correspondence relating to this request. If you made a request to know specific pieces of information you can receive the information electronically or by mail. If you elect to receive the information by mail please provide your mailing address.
    • SECTION 6: Declaration

    • Please complete the below declaration as required so that we may fulfill your request made pursuant to CCPA.

      Declaration in Support of Verified Consumer Request

    • II. Requestor/Declarant Details:

      I acknowledge that I am a California resident and the person making the request noted above, under the California Consumer Privacy Act. I acknowledge that I am making this request in good faith on behalf of myself.

      I certify and declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

    • MM slash DD slash YYYY
    • You can send this declaration to: