California Consumer Privacy Act Request Form


This form is to be used for the submission of any consumer requests under the California Consumer Privacy Act to Five Star Senior Living Inc. and its subsidiaries and affiliates, including FVE Managers, Inc. and Five Star Rehabilitation and Wellness Services, LLC (collectively, “Five Star”).


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








II. California Residency (check one)

III. Request for Access (check all that apply)






IV. Request to Delete (check if applicable)
V. Form of Response (check one)

VI. Authorized Agent (check one)

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.