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Page 23 of 21 <br />Consent to Release — Request from a Government Entity <br />Explanation of Your Rights <br />You have the right to choose what data we release. This means you can let us release all of <br />the data, some of the data, or none of the data listed on this form. Before you give us <br />permission to release the data, we encourage you to review the data listed on this form. You <br />have the right to let us release the data to all, some, or none of the persons or entities listed <br />on this form. This means you can choose which entities or persons may receive the data and <br />what data they may receive. <br />You have the right to ask us to explain the consequences for giving your permission to release <br />the data. You may withdraw your permission at any time. Withdrawing your permission <br />will not affect the data that we have already released because we had your permission to <br />release the data. <br />If you have a question about anything on this form, or would like additional information or <br />explanation, please contact Julie Johnson, City Cleric, 3880 Laverne Avenue North, Suite 100 <br />Lake Elmo, Minnesota 55042; 651.747.3900 or iiohnson@lakeelmo.org, before signing. <br />1, give my permission for the City of Lake Elmo to release <br />data about me to as described on this form. I understand that <br />my decision to allow release of the data to is voluntary. <br />1) <br />The specific <br />data <br />that <br />the <br />City <br />of <br />Lake <br />Elmo <br />may <br />release: <br />2) <br />1 understand the <br />City <br />of Lake <br />Elmo <br />wants <br />to <br />release <br />the data <br />for this <br />reason: <br />3) I understand that although the data are classified as private at the City of Lake Elmo, <br />the classification/treatment of the data at depends on laws or <br />policies that apply to This authorization to release the data <br />expires on <br />Individual data subject's signature <br />Date <br />