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FLORIDA DIGITAL BILL OF RIGHTS
Use this complaint form to report a violation of Sections 501.701-501.722 (Florida Digital Bill of Rights) of the Florida Statutes.
Fields marked with an asterisk (*) are required
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Your Last Name:
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Your First Name:
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Home Address:
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City:
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State:
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Zip Code:
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Home Telephone:
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Cellular Telephone:
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E-mail Address:
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Confirm E-mail Address:
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Username Associated with Account:
1.
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I am submitting this complaint on my own behalf.
Yes
No
If you selected “No,” please provide below the information relating to the person on whose behalf you are filing this complaint.
(If you selected “Yes,” please proceed to statement 2).
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Last Name:
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First Name:
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Home Address:
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City:
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State:
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AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
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Zip Code:
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Home Telephone:
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Cellular Telephone:
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Email Address:
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Confirm Email Address:
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Username Associated with Account:
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Date of Birth:
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What is your relationship with the person whose rights are the subject of this complaint? (Please select one)
Person has authorized me to act for them in exercising their rights pursuant to section 501.705, Florida Statutes (if selected, please provide a written statement giving you authority to act for the person)
Person granted authority to me to act for them under a power of attorney agreement
I am the person’s parent or legal guardian
Other
(Please describe in detail your relationship in the space below)
2.
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Does this complaint involve a user under the age of 18?
Yes
No
3.
This complaint is filed against:
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Name:
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Website:
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Address:
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City:
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State:
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AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
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Zip Code:
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Telephone:
If you desire to submit a complaint against more than one (1) business, please complete and submit a separate complaint for each business.
4.
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Please check all of the following actions you have requested from the business. (Please check all that apply to you or the person on whose behalf you are filing this complaint).
To confirm whether the controller (business) is processing my personal data
To correct inaccuracies in my personal data
To delete any or all personal data provided by or obtained about me
To obtain a copy of my personal data
To opt out of the processing of my personal data for purposes of:
Targeted advertising
The sale of personal data
Profiling
To opt out of the collection of my sensitive data, including precise geolocation data, or the processing of sensitive data
To opt out of the collection of personal data collected through the operation of a voice recognition or facial recognition feature
Another right not listed above
If you selected “Another right not listed above,” please describe in detail the right(s) you requested to exercise in the space provided below.
5.
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Did you previously submit a request to exercise your rights, or the rights of the person for whom you are submitting this complaint, to the business that is the subject of this complaint?
Yes
No
Unknown
If “No,” please skip to question 10.
If “Yes,” please provide a copy of the request and answer questions 6 – 9 that follow.
6.
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Were you required to pay a fee regarding this request? If so, how much was the fee?
Yes
No
Unknown
Amount $:
7.
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Did you receive a response from the business regarding this request?
Yes
No
Unknown
If “Yes,” please provide a copy of this response from the business and any other communications/responses you received from the business?
8.
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If you received a response, did the business indicate it would not take any action?
Yes
No
Unknown
9.
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If you made a request to the business and received a response, did you appeal or request that the business reconsider its decision?
Yes
No
Unknown
If “Yes,” please provide a copy of your communication and the response from the business.
10.
If you believe there is additional information concerning a potential violation of section 501.701, et seq, Florida Statutes, which you believe would assist the Office of the Attorney General in its investigation, please describe this information in detail below:
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Note:
All information submitted with this complaint is subject to public inspection pursuant to Chapter 119, Florida Statutes.
Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his official duty shall be guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082, s. 775.083, or s. 837.06, Florida Statutes.
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