CCPA | SurePayroll By Paychex

As Reseller of SurePayroll under the Reseller Agreement, you provide a “white labeled” version of SurePayroll’s application which means that our mutual clients and/or their California employees will likely look to you first if they wish to submit a consumer request pursuant to CCPA.

This form is only intended to be used by SurePayroll Resellers to submit a formal request for SurePayroll’s assistance in executing a CCPA consumer request received by or through Reseller. As a Reseller, you must complete this form so that SurePayroll may locate the consumer and the required information within its systems. Resellers must verify a consumer before submitting this assistance request. You understand and acknowledge that SurePayroll shall have no responsibility to validate the identity of the requesting consumer, or the accuracy of the information provided below prior to responding to the request.

Please note, if you are a consumer or authorized agent trying to make a CCPA request of SurePayroll, please see the SurePayroll CCPA Privacy Policy for more information surepayroll.com/privacy-policy.

You are

Reseller First Name*

Reseller Last Name*

Reseller E-mail Address*

Re-Enter Reseller Email Address*

Initial Consumer Date of Request*

Reseller Name*

FEIN*

Consumer Identity verification

In order to respond to your request, the CCPA requires us to verify the identity of the consumer exercising their rights under CCPA. Please provide the following information and ensure it matches the data SurePayroll currently has in its systems

Consumer First Name*

Consumer Last Name*

Consumer Phone Number*

Consumer E-mail*

Address Line 1*

Address Line 2

City*

Zip code*

State*

Social Security Number*

Re-enter Social Security Number*

Date of Birth*

The following fields are optional and, if provided, may be used to assist SurePayroll in locating the consumer:

Suffix

Nickname or other name

Consumer request

Consumer Request*

Where we should send the response to your request?*

Email Address*

Mailing Address Line 1

Mailing Address Line 2

Mailing City*

Mailing Zip Code*

Mailing State

If SurePayroll is unable to verify the Consumer’s identity based on the above information, or if the Consumer is not located based on the information provided, your request will be denied, and you will be provided with information on next steps. See our California Privacy Policy for more information.

I acknowledge that any false statement or other misrepresentation made on this form may subject me to civil and criminal penalties. I agree to indemnify and hold harmless SurePayroll, its affiliates and subsidiaries and each of their respective officers, directors, managers, members, employees and agents from any and all liability arising out of any fraudulent statements.

By submitting this form, I declare under penalties of perjury under the laws of the State of California that the foregoing information is true and correct.

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