Ambac - CCPA Request Form

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

State is required

Please select whose information you are requesting: *

Information Type is required

Please specify type of request: *

Please specify type of information request is required

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

Name (Full First and Last Name) *

Name is required

Title (if applicable)

Company (if applicable)

Street Address *

Street Address is required

City *

City is required

State *

State is required

Zip Code *

Zip Code is required

Phone (xxx-xxx-xxxx) *

Phone is required

Email Address *

Email Address is required

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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I have read Ambac Privacy Policy

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