Instructions for Third-Party Authorization

 

Dear California Resident:

 

Before we can fulfill a personal information access or deletion request made by a third party on behalf of a California resident, the California Consumer Privacy Act (CCPA) requires that we obtain evidence that you authorize the third party to make the request on your behalf.

 

Please complete this Third-Party Authorization in order to authorize a third party to make a personal information access or deletion request on your behalf. Completing each line on the declaration with accurate information is required.

 

• Lines 1 to 3 - fill in your name and address (this is for the person whose personal information is the subject of this request).

• Line 4 - fill in your email address for information or questions to you about this request.

• Line 5 – fill in the email address associated with your GeoToll account.

• Line 6 - fill in the third party’s name you are authorizing to make this request on your behalf (Authorized Third Party).

• Line 7 - fill in the email address of the third party you are authorizing to make the request on your behalf.

 

• You must indicate which email address you are requesting the report be sent to. You may only select one email address.

• You must sign the Declaration in front of a notary. The notary will ask for evidence of your identity in order to complete the attached Notary Acknowledgment.

• Once notarized, scan the completed document (the Declaration and Notary Acknowledgment) and upload it according to the instructions provided when you were sent this form.

• If we do not receive this signed and notarized Declaration, we will not be able to complete your request.

• If you have questions regarding completing this form, or use of a different authorization form, contact GeoToll at 855-GEOTOLL.

 

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Third-Party Authorization Declaration

 

1. California Consumer’s Name______________________________________________

2. Consumer’s Residence Address ___________________________________________

3. Consumer’s City, State, Zip Code _______________________________________________

4. Consumer’s email address for communications about this request ______________________________@___________________________

5. Consumer’s Email Address associated with account ______________________________@___________________________

6. Name of Person Authorized to Act on my behalf (Authorized Third Party)_____________________________________________________________

7. Authorized Third Party’s email address for communications about this request______________________________@___________________________

 

Dear GeoToll Representative,

 

I am a resident of the State of California. I am the individual listed above in Line 1.  Please accept this notarized declaration authorizing the Authorized Third Party named above (in Line 6) to act as my representative in connection with my request to access or delete my personal information under the California Consumer Privacy Act of 2018, as amended.

 

I am directing you to send my personal information to the email address above Line 4 __ OR Line 7 __ (mark and 'X' in only one).

 

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

 

Signature: _________________________________Date: _______________

(Signature must be notarized)

 

See Third-Party Authorization Declaration

 

NOTARY ACKNOWLEDGMENT

A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.

 

State of ________________________________

County of _______________________________

 

On _______________ before me, __________________________________ (name and title of officer), personally appeared __________________________________________________________________, who proved to me on the basis of satisfactory and legally sufficient evidence to be the person(s) whose name(s) is/are subscribed to the within Third-Party Authorization Declaration and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of ___________________________ that the foregoing paragraph is true and correct.

 

WITNESS my hand and official seal.

 

Signature ____________________                                                                (Seal)