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North Carolina Department of Justice
North Carolina Department of Justice
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Report a Security Breach

Under North Carolina law, businesses and state and local goverments are required to report security breaches to the Attorney General's Office.
North Carolina Security Breach Reporting Form
Pursuant to the Identity Theft Protection Act of 2005

 
NOTE: If this is a supplement to a security breach notice previously submitted, please email the updated information to consumer@ncdoj.gov

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* Date Security Breach Reporting Form Submitted:
Calendar
   
* Date the Security Breach was discovered:  
Calendar
 
     
   
 
 
Name of company or government agency maintaining or possessing information that was the subject of the Security Breach, if the agency that experienced the Security Breach is not the same entity as the agency reporting the Security Breach (pursuant to N.C.G.S. 75-65(b))
   
 
  
Information Taken:






 
   
* Regarding information breached, if electronic, was the information protected in some manner:


 
   
 
 
* Date affected NC residents were/will be notified:
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If the delay was pursuant to a request from law enforcement pursuant to N.C.G.S. 75-65(c), please attach or mail the written request or the contemporaneous memorandum.
How NC residents were/will be notified?: (pursuant to N.C.G.S. 75-65(e))



Please note if the business demonstrates that the cost of providing notice would exceed two hundred fifty thousand dollars ($250,000) or that the affected class of subject persons to be notified exceeds 500,000, or if the business does not have sufficient contact information or consent to satisfy subdivisions (1), (2), or (3) of this subsection, for only those affected persons without sufficient contact information or consent, or if the business is unable to identify particular affected persons, for only those unidentifiable affected persons. Substitute notice shall consist of all the following:
  • Email notice when the business has an electronic mail address for the subject persons
  • Conspicuous posting of the notice on the Web site page of the business, if one is maintained
  • Notification to major statewide media
Please attach a copy of the notice if in written form or a copy of any scripted notice if in telephonic form.

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 Security code

   
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Please print a copy of your completed form to mail in with any supporting documents and a copy for your records.