Privacy Request Form

I affirm that I am a consumer or an authorized representative of a consumer residing in either California or Oregon and wish to make a request related to Personal Information (aka “personal data”) privacy rights under the CCPA or the OCPA.

I am.
I am not.

These rights are for California and Oregon residents only.

I am a resident of the state of:

California
Oregon

Individual Making the Request:

I am the consumer about whom the request pertains.
I am an agent of the consumer about whom the request pertains.

Note, if you are an agent (parent, legal guardian, or conservator) of the consumer about whom the request pertains, in addition to the information requested about the consumer on the next page, please email us at privacy@populusfinancial.com and provide the following information:

1. To verify your authorization to request on behalf of a California resident, please attach a copy of one or more of the following to your email:

- California Secretary of State authorization,
- written permission from the California resident, or
- power of attorney, or other official legal documentation.

2. To verify your identity, please attach copies of the following to your email:

- valid Government Issued ID (not expired), AND
- a Utility Bill, Bank Statement, or similar documentation to verify your name and address.

3. Please provide agent contact information:

Agent or Agency Name

Agent Email

Agent Phone Number
I am a business contact whose personal information may have been collected through my business interactions with your company.

Type of Request:

Right to Know Categories of Information Collected
Right to Know Personal Information We Are Processing or Have Processed (Including Categories of Personal Information Collected)
Right to Obtain a Copy of Personal Information
Right to Know Specific Pieces of Information Collected
Right to Delete Personal Information
Right to Correct Inaccurate Personal Information

Consumer Contact Information

First Name

Last Name

Address

City

State

Zip Code

Phone Number

Email Address

Business Contact Information

Business Name

Business Phone Number

Consumer's Contact Person at PFG, if known

By submitting this request, I declare under penalty of perjury under the laws of the State of California that I am, or am the proper agent of, the person about whom this request pertains.

I confirm that I would like to submit this request