Required fields are marked with asterisks (*)

Consent to Disclose Personal Information

The Municipality of Clarington is requesting written authorization by means of this form to disclose your personal information to a third party pursuant to section 32(a)(b) of the Municipal Freedom of Information and Protection of Privacy Act, R.S.O., 1990.

Please note that this consent is valid until it is revoked in writing.

Name

Tax Roll Number

Phone number

Email address

Property address

City/Town

Postal code

Please describe, in detail, the information to be disclosed to the third party (e.g., address, details of arrears, account number, phone number) and the reason the information is being requested.

Consent

I, being the individual to whom the personal information relates, do hereby give permission to an authorized staff member of the Municipality of Clarington to disclose my Property Tax Account information to the third party listed below.

Third Party Authorized to Receive the Personal Information

Name of person or company

Email address

Mailing address

City/Town

Postal code

Phone number

Fax number

Personal information contained on this form is collected pursuant to the Municipal Freedom of Information and Protection of Privacy Act. This information is collected to complete the Consent to Disclose Personal Information Form. Any questions related to the collection of this information should be directed to Taxation Services at 905-623-3379 ext. 2650.

Signature of Applicant

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Consent to Disclose Personal Information

Third Party Authorized to Receive the Personal Information