1
GDPR and Data Protection Act 2018
Su
bject Access Request
This form can be used for requesting personal information held by
Horsham District Council, e.g. housing records, benefits and council tax records.
Please
fill this form in electronically then print, sign and post with your ID.
Are you the data subject (i.e. the person the information is about)?
Yes
Current address:
Post code:
Email address:
(we will send an acknowledgement by email to save paper and postage)
Telephone number:
(in case we need to clarify anything with the data subject directly)
Date of birth:
No
If you are the data subject you will be required to supply 2 forms of evidence of your identity
before the information you have requested can be released to you.
This can include a birth certificate, driving licence, passport, recent utility bill.
You can bring this into the Council and we will verify the ID and take a photocopy for you.
Alternatively, photocopies are accepted by post.
You must be acting on behalf of the data subject with their written authority. That authority
must be forwarded with this form to the address below. This can be a letter signed by them or
an official document, e.g. Power of Attorney. No information will be provided without this.
Has the data subject been known by any other name?
Yes No
If yes, other name: (this can help us locate information)
Details of data subject
Las
t name:
Fi
r
st name:
Middle Initial:
Length of time at address:
_______Years
_______Months
(Approximate time is acceptable)
2
Are you requesting information about a child under the age of 13?
Yes - We will require sight of proof of parental responsibility, e.g. birth certificate, passport, court order.
No
If you are not the data subject, please tick the box which describes your relationship with the data
subject that enables you to make this request on their behalf.
S
olicitor
Social Care/Health Professional
Advocate Relative Friend
Other (Please specify):
Housing Association
Is the data subject a current employee of Horsham District Council?
Yes
No
If yes, please provide your payroll number:
As a council we deliver many services. To help us locate any information you think we may
hold, please tick the box(es) below to indicate the services which you believe may hold
information about the data subject.
O
ther (Please specify):
Council Tax
Housing Benefits
Environmental Health
and Licensing
Housing
Community and culture
Electoral Services
Finance
Parking
Building Control
Economic Development
Streetscene and Fleet
Waste and Recycling
Customer Services
Human Resources
and Organisational Development
Planning
Email address:
(we will send an acknowledgement by email to save paper and postage)
Telephone number:
(in case we need to clarify anything with the data subject directly)
If you are not the data subject, please provide your contact details.
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Please provide a description of the personal data which is required, the dates from which we should
search if known, and details of any specific query which may help us idenfity the information required.
Please note that
some information may no longer be available as we regularly dispose of records that
are no longer required in accordance with our Records Management Policy and Retention Schedule.
Declaration by the Data Subject
The declaration below is to be completed by the data subject. Please be aware that
misrepresentation may result in prosecution.
I,
confirm that I am requesting access to my personal data as above and also
confirm that I am the Data Subject and not someone acting on their behalf. I certify that the
information given in this form is true. I understand that it may be necessary for the Council to
obtain further information in order to validate my request and locate the correct information.
Signed:
Dated:
Knowingly or recklessly obtaining or disclosing personal data to which you are not entitled is an
offence under Section 170 of the Data Protection Act 20
18.
(insert your name)
(Please continue on another sheet if necessary.)
Declaration by someone ACTING ON BEHALF of the Data Subject
The declaration below is to be completed by the data subject. Please be aware that
misrepresentation may result in prosecution.
I,
confirm that I am acting on behalf of the data subject and have enclosed my authority to do so.
I certify that the information given in this form is true. I understand that it may be necessary for
the Council to obtain further information in order to validate my request and locate the correct
information.
Signed:
Dated:
(insert your name)
4
ISPS-11f1 v4 2018
Please read the following before submitting your application:
We cannot release personal information without verifying the identity and authority of
the person making the request.
When making an application on behalf of a person who is unable to understand the
Subject Access Request process, you must do so with their best interest only in mind.
We reserve the right to refuse a request if the release of personal information to another
party is believed not to be in the best interest of the data subject.
We respect your right to privacy and are committed to protecting it in accordance with
the GDPR and Data Protection Act 2018. We will use the details provided on this form
to process your request and for no other purpose.
We will share this information with any staff who we believe may hold the information
you have requested. Depending upon the nature of the request, this may involve
sharing information with contractors providing a service on behalf of the Council, e.g.
We may contact other people ('third parties') who are referenced in your information to
gain their consent before disclosing their information to you.
In some circumstances we may need to forward personal details provided by you in
your application to third party agencies (e.g. GP surgeries, police, other councils) in
order to obtain permission to release information relating to them.
By completing and submitting this application you consent to the Council sharing your
information with relevant third parties unless otherwise indicated.
The 1 month period in which the Council is legally required to respond to your request
under the Data Protection Act 2018 will commence after your identity and authority (if
applicable) has been validated. If your request is a complex one the Council is entitled
to extend the deadline from 1 month up to 3 months.
Check list:
I have:
Please return the completed form to:
Data Protection Officer,
Horsham District Council,
Parkside,
Chart Way, Horsham.
West Sussex.
RH12 1RL
If you have any queries about the council's data
protection policies and procedures please e-mail:
dpa@horsham.gov.uk
We are unable to accept
subject access requests via e-mail.
Signed and dated the correct declaration on the form?
Enclosed proof of the data subject's ID?
Enclosed any additional proof of authority and/or parental responsibility?
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