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190435v1 <br />14 <br />Deleted: 1¶ <br />¶ <br /> <br />CONSENT TO RELEASE PRIVATE DATA <br />I, __________________________________, authorize the City of Arden Hills ("City") to <br />(print name) <br />release the following private data about me: <br /> <br />to the following person or people: <br /> <br />The person or people receiving the private data may use it only for the following purpose or <br />purposes: <br /> <br />This authorization is dated ___________ and expires on _____________. <br /> <br />The expiration cannot exceed one year from the date of the authorization, except in the case of authorizations given in connection with <br />applications for life insurance or noncancelable or guaranteed renewable health insurance and identified as such, two years after the <br />date of the policy. <br /> <br />I agree to give up and waive all claims that I might have against the City, its agents and <br />employees for releasing data pursuant to this request. <br /> <br />Dated: ________________ __________________________________ <br /> Signature <br /> <br /> <br /> <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 />Deleted: Exhibit 3 continued¶ <br />Deleted: ¶