Ambac - CCPA Request Form

State of residence of the individual(s) whose information is subject of the request: *

Please select whose information you are requesting: *

Please specify type of request: *

Please specify the information you want corrected and/or deleted:

Name (Full First and Last Name) *

Title (if applicable)

Company (if applicable)

Street Address *

City *

State *

Zip Code *

Phone (xxx-xxx-xxxx) *

Email Address *

If you are an authorized agent, please fill out the following information for the person(s) on whose behalf you are making the request:

If you are an authorized agent, please upload copy of Power of Attorney or Written Authorization:

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