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Exhibit 3 <br /> CONSENT TO RELEASE PRIVATE DATA <br /> I, , authorize the City of ("City")to <br /> (print name) <br /> release the following private data about me: <br /> to the following person or people: <br /> The person or people receiving the private data may use it only for the following purpose or <br /> purposes: <br /> This authorization is dated and expires on . <br /> The expiration cannot exceed one year from the date of the authorization, except in the case of <br /> authorizations given in <br /> connection with applications for life insurance or non-cancellable or guaranteed renewable health <br /> insurance and identified as such, <br /> two years after the date of the policy. <br /> I agree to give up and waive all claims that I might have against the City, its agents <br /> and employees for releasing data pursuant to this request. <br /> Signature <br /> IDENTITY VERIFIED BY: <br /> ❑ Witness: <br /> ❑ Identification: Driver's License, State ID,Passport, other: <br /> ❑ Comparison with signature on file <br /> ❑ Other: <br /> Responsible Authority/Designee: <br />