Consumer Privacy Request Form for Authorized Agents

Residents of certain states are provided certain “rights” to request, correct, or delete certain personal information companies keep. This form acts as the consumer request form to fulfill the rights of consumers under these state laws.

Please note that Cornerstone Capital Bank, SSB does not sell any consumer information. As such, the rights to request the disclosure of information sold or requesting that we stop selling your personal information are not applicable.

If you have a customer relationship with us, we will respond to your request using the contact information that we have on file for you. If you are not our customer and we cannot locate information about you, we will respond to your request using the address you provide below.

We may contact you for additional information to verify your identity and the validity of your request.

Authorized Agent First and Last Name

Authorized Agent Email Address

Authorized Agent Phone Number

Consumer First and Last Name

Consumer Property Address

Consumer Last four of Social Security Number

Consumer Date of Birth

Consumer Email Address

Select Request Type(s)

Request to know personal information
Request to delete personal information

Please note that, if requested, the above rights will be fulfilled within forty-five calendar days. If we are unable to meet the requisite forty-five calendar day deadline, we will inform you of any requisite extension of time, which may include an additional forty-five calendar days.

By submitting this form, I confirm that all of the above information is accurate and true. Furthermore, I confirm that I am the person represented on this form seeking this request(s) and understand that I may be subject to both criminal and civil legal action if determined otherwise.

FOR INTERNAL USE ONLY: Received By

Phone

In-Person

Written Request