CCPA Form | Five Star Senior Living

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

Prospective client or resident

Visitor to Five Star facility or location

Resident’s family member, guest, or legal representative

Current employee

Prospective employee

Former employee

Supplier/vendor

Other…

2. California Residency (check one)

I am a resident of the State of California.

Yes

No

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:

The categories of personal information that Five Star has collected about me

The specific pieces of personal information that Five Star has collected about me

The categories of sources from which Five Star has collected my personal information

Five Star’s business or commercial purpose for collecting my personal information

The categories of third parties with which Five Star shares my personal information

The categories of my personal information that Five Star has disclosed to third parties for a business purpose

Confirmation that Five Star has not sold my personal information

4. Request to Delete (check if applicable)

I hereby request that Five Star delete all personal information it has about me

5. Form of Response (check one)

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

By mail to the address provided above

Electronically to the following email address

6. Authorized Agent (check one)

I am an authorized agent submitting this request on the consumer’s behalf.

Yes

No

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.

CCPA Request Form

Five Star Facility or Location

Consumer Information