Privacy Shield Complaint Form

To qualify for consideration under the EU-U.S. Privacy Shield Framework, complaints must originate from consumers or businesses in one of the participating EU Member States. Your complaint must involve a data privacy concern involving transfer of personally identifiable information (name, address, email address, phone, account information, etc.) from Europe to the United States. To qualify for consideration under the EU-U.S. Privacy Shield Framework, complaints must originate from consumers or businesses in one of the participating EU Member States. Your complaint must involve a data privacy concern involving transfer of personally identifiable information (name, address, email address, phone, account information, etc.) from Europe to the United States.

Section 1: Verification Section 1: Verification

Please mention which country it originates from: Please mention which country it originates from:

Country

Name or other type of identifier used by the US company to individualise you, such as username (mandatory in the case in which the right of access is at stake(1)) Name or other type of identifier used by the US company to individualise you, such as username (mandatory in the case in which the right of access is at stake(1))

Name or Identifier

Section 2: Authorization & Contact Info Section 2: Authorization & Contact Info

Preferred contact (i.e. phone number, e-mail address, mailing address) Preferred contact (i.e. phone number, e-mail address, mailing address) Email Address Phone Number Mailing Address

Email Address

Phone Number

Mailing Address

Your name (for contact purposes) Your name (for contact purposes)

Your Name

Section 3: Nature of Complaint Section 3: Nature of Complaint

If known, which company has sent your data to the US? (Please provide contact information related to this company). If known, which company has sent your data to the US? (Please provide contact information related to this company).

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If known, which is/are the United States companies believed to be involved in processing your personal data? If known, which is/are the United States companies believed to be involved in processing your personal data?

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Please elaborate on the reasons why you believe that your personal data have been transferred from the EU to a Privacy Shield US organisation (for instance, information given in a privacy policy)? Please elaborate on the reasons why you believe that your personal data have been transferred from the EU to a Privacy Shield US organisation (for instance, information given in a privacy policy)?

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Please explain the alleged violation of the Privacy Shield Framework by the US organization Please explain the alleged violation of the Privacy Shield Framework by the US organization

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If you are looking for information or relief, please provide some details If you are looking for information or relief, please provide some details

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Did you already try to resolve your case by contacting the U.S Company (or companies) involved directly?(2) If yes, what was the outcome? Please provide the previous correspondence in that matter. Did you already try to resolve your case by contacting the U.S Company (or companies) involved directly?(2) If yes, what was the outcome? Please provide the previous correspondence in that matter.

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What other measures have you taken to obtain the information or relief requested and what response have you received through those other measures? What other measures have you taken to obtain the information or relief requested and what response have you received through those other measures?

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