[Company Name] - For California Residents Only – CCPA Compliance

This form is available exclusively to California consumers as defined under Section 1798.140(g) of the California Consumer Privacy Act of 2018 ("CCPA"). Under the CCPA, the term "sell" means the disclosure of personal information to a third party in exchange for monetary or other valuable consideration.

[Company Name] is dedicated to protecting your privacy and maintaining full transparency in compliance with the CCPA. We encourage you to review our [California Consumer Privacy Rights Notice] for comprehensive details about our collection, use, and disclosure practices for personal information, including the categories of third parties with whom we may share data as defined by the law.

YOUR RIGHT TO OPT-OUT OF PERSONAL INFORMATION SALES

As a California resident, you have the legal right to request that we do not sell your personal information to third parties. When you exercise this right, we will stop selling your personal data to third parties effective from the date we receive and successfully verify your request.

SUBMIT YOUR DO NOT SELL REQUEST

Please fill out the following information to process your request:

Personal Information:

• First Name: [_________________]
• Last Name: [_________________]
• Email Address: [_________________]
• Phone Number: [_________________]

Mailing Address:

• Street Address: [_________________________________]
• City: [_________________]
• State: [_____]
• ZIP Code: [_________]

Communication Preferences: How would you prefer to be contacted regarding your request? ☐ Mail
☐ Phone Call
☐ Text Message
☐ Email

VERIFICATION AND CERTIFICATION

☐ Certification: By submitting this request form, I hereby certify that I am the individual whose personal information is the subject of this request, or I am legally authorized to act on behalf of such individual. I acknowledge that [Company Name] may need to contact me using the information provided above to verify my identity and process this request in accordance with CCPA requirements.

☐ Acknowledgment: I understand that this request will be processed within the timeframes required by California law, and I may be contacted for additional verification if necessary.

ALTERNATIVE SUBMISSION METHODS

Need assistance or prefer to submit your request another way?

Call Us: 1-800-XXX-XXXX (Toll-Free)
Email Us: privacy@[companyname].com
Mail Us: [Company Name]
Attn: Privacy Rights Department
[Street Address]
[City, State ZIP Code]

IMPORTANT INFORMATION

Processing Timeline

We will acknowledge receipt of your request within 10 business days and complete processing within 15 business days, as required by California law.

Verification Process

To protect your privacy, we may require additional information to verify your identity before processing your request. This verification process helps ensure that personal information is not disclosed to unauthorized parties.

No Discrimination

We will not discriminate against you for exercising your CCPA rights, including by denying services, charging different prices, or providing different levels of service quality.

Authorized Agents

If you are submitting this request through an authorized agent, additional documentation proving authorization may be required.

PRIVACY COMMITMENT

This form represents part of [Company Name]'s comprehensive commitment to safeguarding your personal information and ensuring full compliance with California state privacy laws and all applicable federal privacy regulations.

For questions about our privacy practices or this form, please contact our Privacy Team using the information provided above.

Last Updated: [Date]
Form Version: CCPA-DNS-001