Reporting of Security Events

Safeguards Rule Security Event Reporting Form
The Safeguards Rule requires covered financial institutions to report to the FTC security events affecting 500 or
more people. Complete this form and email it to the FTC at ReportSafeguardsBreach@ftc.gov. Your report may
be made public.
Name of Affected Financial Institution

Contact Person at Affected Financial Institution
Name
Email Address
Date Range of Security Event

Phone Number
Number of People Affected

Type of Information Involved in the Security Event

Summary of Security Event (Additional documents may by attached to your email.)

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