SECTION 1. NAME AND CONTACT INFORMATION

Please provide your information and sign below. Fields with an asterisk ("*") are required in order to complete the form.
First Name*

Last Name*

Common Aliases
(including previous surnames, maiden names, nicknames)

Any business or fictitious business name associated with you

Phone number*
(Please use the XXX-XXX-XXXX phone number format)

Email*

Street Address*

City*

State*
Must be California address to be eligible base on the California Consumer Privacy Act (CCPA)

Zip code*

Are you an applicant for employment or a current or formal employee of Optio Solutions?*

We may contact you if the scope of your request is unclear or does not provide sufficient information for us to conduct a search (for example, if you request “all information about me”). We will begin processing your request as soon as we have verified your identity and have all the information we need to locate your personal information. If we are unable to verify your identity, we will deny the request and inform you of the reason.
By providing us your mailing address, telephone number (including cellular numbers), or e-mail address, you consent to us contacting you by any such method.
SECTION 2. SPECIFIC PIECES OF INFORMATION YOU ARE REQUESTING ACCESS TO OR REQUESTING BE DELETED
To help us understand and respond to your request quickly and efficiently, please provide as much detail as possible about the personal information you are requesting to know or delete in the box below. Please include names, dates and time frames, descriptions, documents, or any other information to help us locate your personal information. For example, you may specify that you are seeking:
- Collection or account information.
- Transaction information.
- Communication histories.
Specific pieces of information you request access to and detailed description

Information you request to be deleted and detailed description

SECTION 3. VERIFICATION OF IDENTITY
In order to verify your request, we require additional information and proof of your identity before we can respond to your request. If you request specific pieces of information, we also require you to sign the declaration below.
We accept a photocopy or a scanned image of your Driver’s License or other government-issued identification as proof of your identity. If you do not have this form of identity, please contact us to discuss whether a different proof of identity may be submitted.
If we are unable to verify your identity, we will deny the request and inform you of the reason.
Date of Birth*

Account Number if applicable

Submit a photocopy of Driver's License or State-Issued Identification*

DECLARATION UNDER PENALTY OF PERJURY
I declare under penalty of perjury under the laws of the State of California, that the information provided on this form is correct and that I am the person whose name appears on this form.
By entering your full name and today's date, you are formally agreeing to the above statement*

Today's Date*

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