Safeguards Rule Security Event Reporting Form

OMB APPROVAL NO.: 3084-0171
EXPIRATION DATE: 12/31/2026

The Safeguards Rule requires covered financial institutions to report to the FTC security events affecting 500 or more people. Your report may be made public. If law enforcement has requested a delay in making this report public, please check the appropriate box below. You should receive a reply email within two business days with instructions for the secure electronic submission of encrypted documents.

Name of Affected Financial Institution

Contact Person at Affected Financial Institution

First Name

Last Name

Phone

Start Date of Notification Event

End Date of Notification Event

Number of Consumers Affected or Potentially Affected

Types of information involved in the Notification Event

Summary of Notification Event

Delayed Publishing

Your report may be made public. If law enforcement has requested a delay in making this report public, please check the appropriate box below.

Law �鶹��ý Delay Requested

Paperwork Reduction Act Statement: An agency may not conduct or sponsor an information collection and a person is not required to respond to this information unless it displays a current valid OMB control number and an expiration date. The control number for this collection is 3084-0171. The estimated average time to read the instructions, gather the information, and complete this form is 5 hours. If you have any comments regarding the burden estimate you can write to �鶹��ý Trade Commission; Assoc. Director - GLB; DPIP; 600 Pennsylvania Ave. N.W.; Mail Stop CC-8232; Washington, D.C. 20580.

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