Privacy Shield Complaint Form

Section 1: Verification

1. To qualify for consideration under the EU-U.S. Privacy Shield Framework, complaints must originate from consumers or businesses in one of the participating EU Member States. Please mention which country your complaint originates from:

2. Your complaint must involve a data privacy concern involving transfer of personally identifiable information (name, address, email address, phone, account information, etc.) from Europe to the United States. If it does not, this issue does not appear to be a data privacy complaint under the Privacy Shield Program.

Does this complaint involve a data privacy concern involving transfer of personally identifiable information from Europe to the United States?

In order to facilitate the handling of your complaint, you should answer all questions in every section. Please note that the use of this form remains optional and you can choose to contact the company in the manner provided in the Privacy Policy. Please bear in mind, though, that the information requested in the form below is needed in order to handle your complaint.

Section 2: Authorization

Before filing your complaint, please note:

By completing and submitting the complaint form on the following pages you will authorize us to process your personal data. You will also authorize us to share that personal data with technical experts, interpreters and translators and government regulators as needed, for purposes of resolving the complaint. We will handle your personal data in accordance with our Privacy Policy.

1. Do you consent to the processing and sharing of my personal data under the terms stated above:

Section 3: Complainant’s Contact Information

1. Name (First Name, Last Name):

2. Email:

3. Mailing Address:

A. Street Address

B. Street Address Line 2

C. City, State / Province

4. Phone Number (Area Code / Phone Number):

Section 4: Nature of Complaint

1. Please provide a brief and well detailed overview of your concerns demonstrating lack of compliance with the Privacy Shield Principles ( such as concerns about sharing, use or protection of personal data, not honoring your opt-out requests etc.:

2. Please elaborate on the reasons why you believe that the Privacy Shield Principles were not complied with:

3. What resolution or further information are you seeking:

4. Any other detail you think will be helpful (optional):

NOTE: If you wish to provide any supporting documentation (such as email correspondence, screenshots or other relevant materials) that demonstrate lack of compliance with the Privacy Shield Principles, please send them named and labeled over to Thank you.