Laserfiche WebLink
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 or <br />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 understand <br />that I may cancel this consent at any time prior to the information being released and that <br />in any event this consent expires automatically 90 days after signing. By signing this <br />document, I give my full and voluntary consent to the City to release the above -listed data to <br />the persons identified in this release, and I waive any and all claims against the City for the <br />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: <br />Exhibit 6 <br />MU125\11\1101989.vI <br />