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EXHIBIT A <br />HUMAN SERVICES AGENCY <br />Law Enforcement Request for Protected Personal Information from Clarity HMIS <br /> <br />[NAME OF LAW ENFORCEMENT AGENCY] hereby requests disclosure of the following Protected Personal <br />Information (PPI): <br />□ Client name <br />□ Client description <br />□ Date of birth <br />□ Last known address / location <br />□ Telephone number <br />□ Email address <br />□ Other: ____________________ <br /> <br />Purpose for which PPI is requested: <br />To assist in the identification of individuals living in a homeless encampment located at [ADDRESS] <br />(in the City of _________) who have received homeless outreach services and offer of available <br />shelter pursuant to the [CITY ORDINANCE OR CODE SECTION] and are in violation of [CITY <br />ORDINANCE OR CODE SECTION] as follows: <br />__________________________________________________________________________________ <br />__________________________________________________________________________________ <br />__________________________________________________________________________________ <br /> <br />By signing below, the requesting law enforcement agency confirms that the requested information is <br />relevant and material to a legitimate law enforcement investigation; that the request is specific and <br />limited in scope to the extent reasonably practicable in light of the purpose for which the information is <br />sought; and that de-identified information cannot be used to accomplish the purpose of the disclosure. <br /> <br />Date: _____________________ _____________________________________________ <br /> Name <br />_____________________________________________ <br />Title <br />(Must be a supervisory official of the law enforcement <br />agency seeking the PPI) <br />_____________________________________________ <br />Law enforcement agency <br />(City Police Department) <br />8.H. - Page 18 of 31 <br />175