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For official use only

1601 Willow Road

Menlo Park, California 94025

WHATSAPP EMERGENCY DISCLOSURE REQUEST FORM

This form is to be filled out if you are a sworn law enforcement official, believe that WhatsApp may have information to assist in
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averting an emergency involving risk of death or serious physical injury and have no time to secure formal legal process. Please
respond to the five (5) questions below to assist WhatsApp in determining whether to exercise its discretion to disclose information
to you pursuant to 18 U.S.C. § 2702(b)(8) and § 2702(c)(4).

1. What is the nature of the emergency (e.g. kidnapping, suicide, missing person, threat to national security) and whose death
or serious physical injury is threatened?

2. Please describe the imminent nature of the threat or provide information that suggests there is a specific deadline before
which it is necessary to receive the requested information and/or that suggests there is a specific deadline on which the act
indicated in response to Question 1 will occur (e.g., tonight, tomorrow at noon, etc.).

3. What specific information in WhatsApp’s possession related to the emergency are you seeking? SPECIFY THE WHATSAPP
ACCOUNT NUMBER (INCLUDING COUNTRY CODE) FOR WHICH THE INFORMATION IS BEING
REQUESTED. (Note: Please do not request everything WhatsApp has in its possession, as this type of request will likely
result in our response being delayed or in our denying the request.)

4. Please describe how the information you are requesting will assist in averting the risk of death or serious physical injury.

5. If a message that was sent from a WhatsApp account is the basis for the belief that there is a risk of death or serious physical
injury, please attach a copy of the message(s) to this form.

I hereby certify under penalty of perjury that the information provided on this form is true.

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Name Title

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Agency Email

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Phone Mobile

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Manual Signature Date