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11/15/21, 4:50 PM <br />Revize Online Forms <br />PRIVACY NOTICE: I understand the information provided in this application may be considered private or confidential data. I further <br />understand that I may not be required by law to provide such information. The purpose of providing such information is to aid the City in <br />its determination on said application. I acknowledge that providing, or failing to provide, such information may affect the City's <br />determination on said application. I understand this information will be made available to the City of Mounds View, its City Council, agents <br />and representatives, as well as the Minnesota Department of Revenue, the Internal Revenue Service, or any other person or entity <br />authorized by law to receive said information. I release the City of Mounds View from any and all liability for its receipt and use of data <br />received pursuant to this application. <br />Applicant Signature <br />Richard R. Herod, III <br />Upload a File (Additional Information/Forms/Copy of Drivers <br />License or I D <br />Choose File No file chosen <br />TO PAY CLICK HERE <br />Date <br />11/15/2021 <br />Format: MM/DD/YYYY <br />Upload a File (Additional Information/Forms/Copy of Drivers <br />License or ID <br />[Choose File No file chosen <br />https://moundsviewmn.rja.revize.com/reports/180204 3/3 <br />