CCPA Request Form

Five Star Facility or Location


Consumer Information


1. Relationship to Five Star (check all that apply)

Relationship to Five Star (Checkboxes)

2. California Residency (check one)

I am a resident of the State of California.

3. Request for Access (check all that apply)

I hereby request that Five Star provide me with the following information, in each case with respect to Five Star’s processing of my personal information during the past twelve (12) months:

4. Request to Delete (check if applicable)

5. Form of Response (check one)

I request that Five Star respond to this request by the following means:

6. Authorized Agent (check one)

I am an authorized agent submitting this request on the consumer’s behalf.
If you checked yes above, you must provide written proof that you are authorized to act on the consumer’s behalf, such as a signed and notarized Power of Attorney.


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Please contact us at (888) 574-4722 or [email protected] if you have any questions about this form.

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