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The form requires accurate completion of consumer details, service address, customer status, communication email, authorized third party name and email, case number, and selection of the delivery email for the report. The declaration must be signed before a notary and submitted via the American Water Privacy Portal or mailed to American Water Works with the notary acknowledgment included.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/third-party-request-authorization-form-third-party-authorization-instructions/283797/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/third-party-request-authorization-form-third-party-authorization-instructions/283797.png","ImageObject",442,249,{"name":88,"@type":89},"Himbo","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-30","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":25},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What is the purpose of the Third-Party Authorization form under the CCPA?","Question",{"text":108,"@type":109},"It authorizes a third party to act as the representative to submit a personal information access or deletion request on behalf of a California resident under the CCPA.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Which information must be completed in the form (Lines 1–9)?",{"text":113,"@type":109},"The consumer’s name and service address, city/state/zip, current or former customer status, the consumer email for request communications, the authorized third party’s name and email, the case number, and the single email address where the report should be sent.",{"name":115,"@type":106,"acceptedAnswer":116},"Why must the declaration be notarized, and what happens if it is not provided?",{"text":117,"@type":109},"The declaration must be signed in front of a notary to include identity evidence via the attached notary acknowledgment. If the signed and notarized declaration is not received, the request cannot be completed and may be closed.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},283797,1790051298,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":25,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},687197100911,"https://ap-avatar.wpscdn.com/avatar/a000239b6f1da00475?x-image-process=image/resize,m_fixed,w_180,h_180&k=1785132997149421697","Instructions for Third-Party Authorization  \nDear California Resident:  \nBefore we can fulfill an access or deletion request made by a third party on behalf of a California resident, the California Consumer Privacy Act (CCPA) requires American Water to obtain evidence that you authorize the third party to make the request on your behalf.  \nIn order to authorize a third party to make a personal information access or deletion request on your behalf, please complete this Third-Party Authorization. Completing each line on the declaration with accurate information is required.  \nThe following are the instructions for completion of the Third-Party Authorization form:  \n• Lines 1 – fill in your name (this is for the person whose personal information is the subject of this request , i.e. the consumer) .  \n• Line 2 – fill in your service address (i.e. the place where you receive American Water services)  \n• Line 4 – indicate whether you are a current or former customer.  \n• Line 5 – fill in your email address for information or questions to you about this request.  \n• Line 6 – fill in the third party’s name you are authorizing to make this request on your behalf (Authorized Third Party) .  \n• Line 7 – fill in the email address of the third party you are authorizing to make the request on your behalf.  \n• Line 8 – insert the Case Number you received when submitting your request.  \n• Line 9 – indicate which email address you request the report be sent to. You may only select one email address.  \n• You must sign the Declaration in front of a notary. The notary will ask for evidence of your identity in order to complete the attached Notary Acknowledgment.  \n• Once the Declaration and Notary Acknowledgment are complete, you can:  \no Upload it to the American Water Privacy Portal  \no Or mail the completed form to:  \nAmerican Water Works  \nAttn: Enterprise Security  \n1 Water St Camden, NJ 08102  \n• If we do not receive this signed and notarized Declaration (pages 2 and 3) , we will not be able to complete your request and your request may be closed.  \nThird-Party Authorization Declaration  \n(1) California Consumer’s Name    \n(2) Consumer’s Service Address    \n(3) Consumer’s City, State, Zip    \n(4) Consumer is a current or former customer: ☐ yes ☐ no  \n(5) Consumer’s email address for communications about this request  (6) Name of Person Authorized to Act on my behalf (Authorized Third Party)  (7) Authorized Third Party’s email address    \n(8) Case Number    \nDear American Water ,  \nI am the individual named above in Line 1 and a resident of the State of California.  \nPlease accept this notarized declaration authorizing the Authorized Third Party named above (in Line 6) to act as my representative in connection with my request to access or delete my personal information under the California Consumer Privacy Act of 2018, as amended.  \nSend my personal information to the email address above on:  \n(9) ☐ Line 5 (me) OR ☐ Line 7 (Authorized Third Party)  \nI certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct.  \nSignature:   Date:    \n(Signature must be notarized)  \nNotary Acknowledgment  \nA notary public or other officer completing thiscertificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.  \nState of   County of    \nOn   before me,   (name and title of officer), personally appeared   , who proved to me on the basis of satisfactory and legally sufficient evidence to be the person(s) whose name(s) is/are subscribed to the within Third-Party Authorization Declaration and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.  \nI certify under PENALTY OF PERJURY under th","cbCaiiDHimY3jPVc","https://ap.wps.com/l/cbCaiiDHimY3jPVc","pdf",122667,"English","# Third-Party Authorization Instructions\n## Declaration Completion Lines 1–9\n## Notary Signing and Submission Requirements\n# Third-Party Authorization Declaration\n## Required Information Fields\n# Notary Acknowledgment","[{\"question\":\"What is the purpose of the Third-Party Authorization form under the CCPA?\",\"answer\":\"It authorizes a third party to act as the representative to submit a personal information access or deletion request on behalf of a California resident under the CCPA.\"},{\"question\":\"Which information must be completed in the form (Lines 1–9)?\",\"answer\":\"The consumer’s name and service address, city/state/zip, current or former customer status, the consumer email for request communications, the authorized third party’s name and email, the case number, and the single email address where the report should be sent.\"},{\"question\":\"Why must the declaration be notarized, and what happens if it is not provided?\",\"answer\":\"The declaration must be signed in front of a notary to include identity evidence via the attached notary acknowledgment. If the signed and notarized declaration is not received, the request cannot be completed and may be closed.\"}]","Third-Party Request Authorization Form - Third-Party Authorization Instructions | PDF",1789619681]