City OF MPLS 4D Government Data Practices Act Disclosure Statement
Name of client signing this form:
Client first name Client middle name Client last name
The City of Minneapolis has provided financial assistance to the property listed below which requires the submission of certain private information that relates to your application to occupy, or continue to occupy, a rent restricted unit in the following property (“Property”).
1717 26th AVE N MPLS MN 55411
1719 26th AVE N MPLS MN 55411
Some of the information you are being asked to provide may be considered private or confidential under the Minnesota Government Data Practices Act (MGDPA), Minnesota Statutes Chapter 13. Section 13.04(2) of this law requires that you be notified of the matters included in this Disclosure Statement before you are asked to provide that information. The Owner of the Property may also ask you to supply information that relates to your application. The Owner’s request for information is not governed by the Minnesota Government Data Practices Act.
1. The City of Minneapolis is asking for information necessary for the administration and management of a local program to provide housing for low and moderate income families. Some of the information may be used to establish your eligibility to initially occupy, or to continue to occupy, a unit in the Property. Other information may be used to assist the City in the evaluation and management of some of the programs it operates.
2. As part of your application, you are asked to supply the information listed in Attachment 1.
3. The information asked for in Attachment 1 will be used to establish your eligibility to occupy a unit in the Property. If you refuse to supply any portion of the information, you may not qualify for initial or continued occupancy of a unit in the Property.
4. The Owner may also ask for information to determine whether or not it will rent a unit in the Property to you. If you supply, or refuse to supply, any information requested by the Owner, it will NOT affect a decision by the City, but could affect the Owner’s decision to rent a unit to you. The determination by the Owner is
separate from the City’s determination and the City does not participate in the Owner’s decision.
5. All of the information listed on Attachment 1 will be accessible to staff of the City (and its agents) and may be made available to staff of the Office of the Minnesota State Auditor or Attorney General, the United States Internal Revenue Service (IRS) and other persons and/or governmental entities who have statutory authority to review the information, investigate specific conduct, and/or take appropriate legal action including but not limited to law enforcement agencies, courts and other regulatory agencies. The information may also be provided by the City to the Owner’s management agents of the Property.
6. This Disclosure Statement remains in effect for as long as you occupy a unit in the Property.
I was (We were) supplied with a copy of and have read this Government Data Practices Act Disclosure Statement and the Attachments identified in #2 above. I acknowledge that the information I am providing on Attachment 1 will be relied upon for purposes of determining my income eligibility to occupy the Property and declare under penalty of perjury, which is a felony offense, that my statements on Attachment 1 and the supporting information provided are true and correct.
By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.
Suignature Signature Date Date
Attachment 1, City of Minneapolis, 4D Program
1. Information regarding the household composition including the name(s) and age(s) of all members in the household.
2. The income tax returns for all household members 18 or older who filed a federal income tax return in the year prior to the date of this Government Data Practices Act Disclosure Statement.
3. If there are any members of the household 18 or older who did not file a federal income tax return in the year prior to the date of this Government Data Practices Act Disclosure Statement, each such member shall certify by signing below that they were not required by law to file a federal income tax return.
Household MemberParagraph