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MPD PROPERTY AND EVIDENCE UNIT <br />Room 33, City Hall <br />Minneapolis, Minnesota 55415 <br />(612) 673-2932 <br />NAME (LAST, FIRST, MIDDLE). <br />BIRTH DATE (VOLUNTARY INFORMATION FOR IDENTIFICATION PURPOSES). <br />ALIAS /MAIDEN NAME <br />I hereby authorize and grant my informed consent to permit the Minnesota Department of Human Services to release <br />to and make available to the Minneapolis Police Property and Evidence Unit and /or its agents and /or representatives <br />data classified as private which concerns me and which may be in your possession. The data which I authorize to be <br />released consists of private data as defined by Minnesota Statute 13.02, Subd. 12, and has been collected by you as a <br />result of my contact and associations with you, and /or your agents and representatives. The information for which <br />release is authorized includes all data which has been collected, created, received, retained or disseminated in <br />whatever form which in any way related to my dealing with you or your agency. This information includes, but is not <br />limited to, data regarding mental illness or chemical dependency. <br />I understand that access to this information is to determine my eligibility to possess a firearm. <br />This authorization shall be valid for a period of one year but I reserve the right to, at any time prior to that expiration, <br />cancel the written authorization by providing written notice to the Minneapolis Property and Evidence Unit or to the <br />Minnesota Department of Human Services. <br />MP -8100 Rev. 5/90 <br />SIGNATURE (FULL NAME) DATE SIGNED <br />Page 87 <br />