FECHA: _____________________________ NÚMERO DE RADICACIÓN: ______________________ Datos del titular de los datos personales APELLIDOS: __________________________________ NOMBRES: __________________________________________ IDENTIFICACIÓN: CC ____ TI _____ OTRO _____

NÚMERO: ___________________________________________

DIRECCIÓN FÍSICA O ELECTRÓNICA: _________________________________________________________________ Datos personales en relación con los cuales se presenta la solicitud o reclamo: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Solicitud o Descripción de los hechos que dan lugar al reclamo: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________

___________________________________________________ Firma