the Rubicon Project

I, the undersigned individual, do hereby swear, certify, and attest that:

1. I am a citizen and/or resident of

Country

State

Other

2. Please complete for the access you are requesting:

Mobile Phone:
I own and operate one or more mobile devices with the following Device Identifier(s) (as that term is used in Rubicon Project’s Data Subject Rights Notice):

Mobile

Browser:
I own and operate a device on which is stored at least one cookie labeled either “khaos” or “ruid”, set by the rubiconproject.com domain, which contains the following string(s) of text:

Browser

Please attach screenshot reflecting cookie and/or device ID(s).

Drop files here or

Accepted file types: jpg, jpeg, png, Max. file size: 2 MB, Max. files: 5.

Limit of 5 files. Maximum file size: 2MB each.

3. I have the authority under relevant laws, rules, and regulations, to submit a subject access request for personal data associated with the above-listed identifiers; and

4. I am not requesting this information for any fraudulent, criminal, malicious, or otherwise unlawful purpose.

I declare under penalty of perjury that the foregoing is true and correct.

Data Subject/Consumer:

Signature*

Full Name*

Email Address*