Assessment of Possible Unauthorized Access
Assessment of Unauthorized Access
To Sensitive Customer Information
|Date of Incident |Date Bank was Notified |Date Regulator was Notified |
Type of Sensitive Customer Information* potentially compromised:______________________________
_____________________________________________________________________________________
Information system(s) involved: __________________________________________________________
_____________________________________________________________________________________
Service Provider involved? ρNo ρYes (Name)____________________________________________
Nature/Scope of Incident: ________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Results of Assessment
ρ Likely that Sensitive Customer Information has been or will be misused**
ρ Not likely that Sensitive Customer Information has been or will be misused
Customer(s) Affected (If specific customers can not be identified, all customers in affected group must be notified)
__________________________________________________________________________________________________________________________________________________________________________
Action Taken
Steps taken to prevent further access or use of the information: __________________________________
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
| | |Consumer Reporting Agencies notified (only if large|
|SAR Filed ρYes ρNo |Law Enforcement Notified ρYes ρNo |numbers of customers will be sent notices) ρYes |
|Date ___________________________ |Date ____________________________ |ρNo |
| | |Date ____________________________ |
Method of delivery of Notice to customer:
ρ Telephone ρ Mail ρ Electronic (only if customer has previously agreed to receive communications electronically)
Date Notice delivered _______________
*Sensitive Customer Information: Customer’s name, address, or telephone number, in conjunction with: 1) SSN; 2) Driver’s License number; 3) Account number; 4) Credit or Debit card number; or, 5) PIN number, or; password or any combination of information allowing someone to log onto or access the customer’s account, such as user name and password or password and account number.
**Attach copy of Customer Notice to this form
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