Form - SEC Reporting Requirements Delay Request Form

To request a reporting delay, victim companies must contact the FBI directly by using the form below or through the U.S. Secret Service, the Cybersecurity and Infrastructure Security Agency, the Department of Defense, or another sector risk management agency.

A red asterisk (*) indicates a required field.

*Company Name:

When did the cyber incident occur?

*Date:

*Time:

*Time zone:

When did you make a determination to disclose a cyber incident via 8k?

Failure to report this information immediately upon determination will cause your delay-referral request to be denied.

*Date:

*Time:

*Time zone:

Are you already in contact with the FBI or another U.S. government agency regarding this incident? If so, provide the names and field offices of the FBI points of contact or information regarding the U.S. government agency with whom you're in contact.

*Describe the incident in detail.

Describe any known or suspected intrusion vectors, including any identified vulnerabilities.

Describe any data or infrastructure that was affected (if any) and how it was affected.

Describe the operational impact on your company, if known.

*Is there confirmed or suspected attribution of the cyber actors responsible?

Yes

Please provide details about the confirmed or suspected cyber actors responsible.

*What is the current status of any remediation or mitigation efforts?

Location of Incident

*Address:

Address (continued):

Suite/Apt./Mail Stop:

*City:

*Country:

*State:

Zip Code/Route:

*Who are your company's points of contact for this matter? Provide the name, phone number, and email address of personnel you want the FBI to contact to discuss this request.

*Has your company previously submitted a request for delay in SEC reporting, or is this the first submission?

Yes, there have been previous requests

No, this is the first time

If you have previously submitted a delay request, please include details about when DOJ made its last delay determination(s), on what grounds, and for how long it granted the delay (if applicable).

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