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