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Exhibit 6 <br />489828v3 DTA MU125-11 <br />EXHIBIT 6 <br />CONSENT TO RELEASE PRIVATE DATA <br />I, , authorize the City of Mounds View (“City”) to release the <br />print name) <br />following private data about me: <br />to the following person(s) or entity(ies): <br />The person(s) or entity(ies) receiving the private data may use it only for the following purpose <br />or purposes: <br />This authorization is dated _________________and expires on___________________________ <br />I understand that my records are protected under state privacy regulations and cannot be <br />disclosed without my written consent unless otherwise provided for by law. I also <br />understand that I may cancel this consent at any time prior to the information being <br />released and that in any event this consent expires automatically 90 days after signing. By <br />signing this document, I give my full and voluntary consent to the City to release the above- <br />listed data to the persons identified in this release, and I waive any and all claims against <br />the City for the disclosure of private data about me in accordance with this document. <br />Signature <br />Signature of parent or guardian <br />if data subject is under 18 years of age) <br />IDENTITY VERIFIED BY: <br />Witness: x______________________________ <br />Identification: Driver’s License, State ID, Passport, <br />other:__________________________________ <br />Comparison with signature on file <br />Other:__________________________________ <br />Responsible Authority/Designee: ___________________________________________