Personal Information Request Form

Personal Information Request

(Please select which of the following rights you wish to exercise)

Right to Know How We Collect, Use, and Share Your Personal Information The right to obtain information regarding how we collect, use, and share your personal information.

Right to Know Specific Pieces of Personal Information (“Right to Access”) The right to obtain a copy of the specific pieces of personal information we have collected about you.

Right to Know the Categories of Personal Information The right to obtain a copy of the categories of personal information we have collected about you.

Right to Deletion The right to request deletion of personal information we have collected from you, subject to certain exceptions under applicable law.

Right to Correct The right to correct inaccuracies in your personal information that we have collected about you.

Right of Portability The right to transfer your personal information that we have collected about you in a format that can be transmitted to another service provider.

Right to List of Third Parties The right to obtain a list of third parties we have disclosed personal information to, which may include your personal information.

Right to Opt Out The right to opt out of our use of your personal information for targeted advertising, our sale of it, or certain profiling uses that may produce harmful effects. You can also manage your opt-out preferences through our website cookie preference settings.

Right to Limit If you want to limit the use or disclosure of sensitive personal information, you can do so through the Global Privacy Control opt-out mechanism.

Verification

Miller Nash (“we”) need to verify your identity before we comply with your request. You can provide any of the following pieces of verification information: full name, financial account number on file, mailing address, email address, or phone number.

If you are only requesting the disclosure of the categories of personal information we have about you, only two (2) pieces of information are required. For all other requests, three (3) pieces of information are required.

We may ask for additional information to fulfill your request.

1st Piece of Information

2nd Piece of Information

3rd Piece of Information

Additional Information

Please provide additional details below regarding your request if necessary:

We may ask for additional information to fulfill your request.

Declaration

I declare that (1) the contents in this request are accurate and (2) I am the person whose personal information is the subject of this request (or their agent).

Printed Name *

Date *

Address *

Phone No. *

Age *

How would you like to receive the information you have requested? *

Email

Mail

Name

Email Address

Physical Address

If you are making this request on behalf of someone else as their agent, provide the following information:

I declare under penalty of perjury that I am the authorized agent of the person whose personal information is the subject of this request. A notarized statement containing my signature and the signature of the person I represent is attached to confirm my authority to make this request.

Upload your notarized statement here:

Agent Printed Name and Company

Today's Date

Agent Address

Agent Phone No.

Personal Information Request Form

Miller Nash LLP (“Miller Nash”) Personal Information Request Form