Common use of Privacy Act Notice Clause in Contracts

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Xxxxxxx uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. I acknowledge my responsibility to respect the confidentiality of student records and to act in a professional manner in the handling of student data. I will ensure that confidential data, including personally identifiable information (PII) is not created, collected, stored, maintained, or disseminated in violation of state and federal laws. Furthermore, I agree to the following guidelines regarding the appropriate use of student data collected by myself or made available to me from other school or district employees: • I will comply with school district confidentiality policies, as well as state and federal confidentiality laws including Family Educational Rights and Privacy Act (FERPA): xxxx://xxx.xx.xxx/offices/OM/fpco/ferpa/, and the Children’s Online Privacy Protection Act (COPPA): xxxxx://xxx.xxx.xxx/enforcement/rules/rulemaking-regulatory-reform- proceedings/childrens-online-privacy-protection-rule • Student data will only be accessed for students for whom I have a legitimate professional need and will be used for the sole purpose of improving student achievement or ensuring student and school safety. • I understand that student specific data is never to be transmitted via email or as an email attachment unless the file is encrypted, password protected or PII has been redacted. • I will securely log in and out of the programs that store student specific data. I will not share my password nor keep password information in an accessible location. Any documents I create containing student specific data will be stored securely within the district network or within a password-protected environment. I will not store student specific data on any personal computer and/or external devices that are not password protected. (External devices include but are not limited to USB/thumb drives, external hard drives, cell phones and tablets.) • I will not record any digital or online virtual learning or assessment sessions that would become part of a student's record. • Regardless of its format, I will treat all information with respect for student privacy. I will not leave student data in any form accessible or unattended, including information on a computer display or hard copy documents. • Any digital or hard copy records containing PII will be returned to the district office or school site when employment or job assignment has been completed or terminated. By signing below, I acknowledge, understand and agree to accept all terms and conditions of the Xxxxxx Xxxx Unified School District’s Student Data Confidentiality Agreement. Signature of Employee/Contractor Date Print Name Job Title TO TECHNOLOGY SERVICES AGREEMENT FOR CALIFORNIA EDUCATION CODE 49073.1 COMPLIANCE This Addendum No. is entered into between Xxxxxx Xxxx Unified School District (“District”) and (“Service Provider”) on .

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRAXXX, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Xxxxxxx Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. I acknowledge my responsibility to respect the confidentiality OFFICE POLICY MANUAL for CALIFORNIA LICENSEES Park and Refer Inc. Updated Table of student records and to act in a professional manner in the handling of student dataContents 1. I will ensure that confidential dataREFERRAL ONLY REAL ESTATE TRANSACTIONS 1 2. BROKERAGE RELATIONSHIPS 2 3. LICENSEE'S PURCHASE AND SALE OF PROPERTY 2 4. LICENSE RENEWALS, including personally identifiable information (PII) is not created, collected, stored, maintained, or disseminated in violation of state and federal lawsTRANSFERS AND RESPONSIBILITY FOR CONTINUING EDUCATION 2-3 5. Furthermore, I agree to the following guidelines regarding the appropriate use of student data collected by myself or made available to me from other school or district employees: • I will comply with school district confidentiality policies, as well as state and federal confidentiality laws including Family Educational Rights and Privacy Act (FERPA): xxxx://xxx.xx.xxx/offices/OM/fpco/ferpa/, and the Children’s Online Privacy Protection Act (COPPA): xxxxx://xxx.xxx.xxx/enforcement/rules/rulemaking-regulatory-reform- proceedings/childrensDELEGATION OF AUTHORITY AND SUPERVISION 3-online4 6. PROPERTY MANAGEMENT - BUSINESS SALES 4 7. TRAINING 5 8. FAIR HOUSING AND DISCRIMINATION 5 9. DO NOT CALL 5-privacy7 10. ANTI MONEY LAUNDERING 7-protection8 11. SEXUAL AND OTHER UNLAWFUL HARASSMENT 9 12. SAFETY AND PREMISES SECURITY XXXXXXXX 00 00. HANDLING OF CONFIDENTIAL INFORMATION 10-rule • Student data will only be accessed for students for whom I have a legitimate professional need and will be used for the sole purpose of improving student achievement or ensuring student and school safety. • I understand that student specific data is never to be transmitted via email or as an email attachment unless the file is encrypted, password protected or PII has been redacted. • I will securely log in and out of the programs that store student specific data. I will not share my password nor keep password information in an accessible location. Any documents I create containing student specific data will be stored securely within the district network or within a password-protected environment. I will not store student specific data on any personal computer and/or external devices that are not password protected. (External devices include but are not limited to USB/thumb drives, external hard drives, cell phones and tablets.) • I will not record any digital or online virtual learning or assessment sessions that would become part of a student's record. • Regardless of its format, I will treat all information with respect for student privacy. I will not leave student data in any form accessible or unattended, including information on a computer display or hard copy documents. • Any digital or hard copy records containing PII will be returned to the district office or school site when employment or job assignment has been completed or terminated. By signing below, I acknowledge, understand and agree to accept all terms and conditions of the Xxxxxx Xxxx Unified School District’s Student Data Confidentiality Agreement. Signature of Employee/Contractor Date Print Name Job Title TO TECHNOLOGY SERVICES AGREEMENT FOR CALIFORNIA EDUCATION CODE 49073.1 COMPLIANCE This Addendum No. is entered into between Xxxxxx Xxxx Unified School District (“District”) and (“Service Provider”) on .11

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Xxxxxxx uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. I acknowledge my responsibility to respect OFFICE POLICY MANUAL for COLORADO LICENSEES Park and Refer Inc. Updated Table of Contents 1. REFERRAL ONLY REAL ESTATE TRANSACTIONS 1 2. BROKERAGE RELATIONSHIPS 2 3. LICENSEE'S PURCHASE AND SALE OF PROPERTY 2 4. LICENSE RENEWALS, TRANSFERS AND RESPONSIBILITY FOR CONTINUING EDUCATION 2-3 5. DELEGATION OF AUTHORITY AND SUPERVISION 3-4 6. PROPERTY MANAGEMENT - BUSINESS SALES 4 7. TRAINING 5 8. FAIR HOUSING 5 9. DO NOT CALL 5-7 10. ANTI MONEY LAUNDERING 7-8 11. SEXUAL AND OTHER UNLAWFUL HARASSMENT 9 12. SAFETY AND PREMISES SECURITY XXXXXXXX 00 00. HANDLING OF CONFIDENTIAL INFORMATION 10-11 14. FILE LOCATION 12 15. GENERAL - COMPLIANCE 12 Office Policy Manual 1 for Park and Refer Inc. Brokerage Firm General. Below is the confidentiality text of student records the Office Policy Manual (“Manual”) for Park and to act Refer Inc. (“Brokerage Firm”) addressing the policies of Brokerage Firm and the Employing Broker and the independent contractors/licensees (each a “Licensee”) working under them. Unless the context requires otherwise, whenever used in a professional manner in this Manual, the handling of student data. I will ensure that confidential data, including personally identifiable information (PII) is not created, collected, stored, maintained, or disseminated in violation of state and federal laws. Furthermore, I agree term “Broker” shall refer to the following guidelines regarding Employing Broker and a Managing Broker, if Brokerage Firm or the appropriate use of student data collected by myself or made available to me from other school or district employees: • I will comply with school district confidentiality policies, as well as state and federal confidentiality laws including Family Educational Rights and Privacy Act (FERPA): xxxx://xxx.xx.xxx/offices/OM/fpco/ferpa/, and the Children’s Online Privacy Protection Act (COPPA): xxxxx://xxx.xxx.xxx/enforcement/rules/rulemaking-regulatory-reform- proceedings/childrens-online-privacy-protection-rule • Student data will only be accessed for students for whom I have Employing Broker has designated such a legitimate professional need and will be used for the sole purpose of improving student achievement or ensuring student and school safety. • I understand that student specific data is never to be transmitted via email or as an email attachment unless the file is encrypted, password protected or PII has been redacted. • I will securely log in and out of the programs that store student specific data. I will not share my password nor keep password information in an accessible location. Any documents I create containing student specific data will be stored securely within the district network or within a password-protected environment. I will not store student specific data on any personal computer and/or external devices that are not password protected. (External devices include but are not limited to USB/thumb drives, external hard drives, cell phones and tabletsManaging Broker.) • I will not record any digital or online virtual learning or assessment sessions that would become part of a student's record. • Regardless of its format, I will treat all information with respect for student privacy. I will not leave student data in any form accessible or unattended, including information on a computer display or hard copy documents. • Any digital or hard copy records containing PII will be returned to the district office or school site when employment or job assignment has been completed or terminated. By signing below, I acknowledge, understand and agree to accept all terms and conditions of the Xxxxxx Xxxx Unified School District’s Student Data Confidentiality Agreement. Signature of Employee/Contractor Date Print Name Job Title TO TECHNOLOGY SERVICES AGREEMENT FOR CALIFORNIA EDUCATION CODE 49073.1 COMPLIANCE This Addendum No. is entered into between Xxxxxx Xxxx Unified School District (“District”) and (“Service Provider”) on .

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Xxxxxxx uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished. Circle the minor’s name and furnish the minor’s SSN. DEPARTMENT OF HUMAN SERVICES Child Care Assistance Program 0000 Xxxx Xxxxxx Xxxxx Xxxx Xxxxxxx, CO 80524 (000) 000-0000 Fax: (000) 000-0000 PAYMENT OPTION Dear Qualified Exempt Non-Licensed Child Care Provider, You have a choice of how you will receive your child care payments. Below are your options and a little information about each choice. Direct Deposit • Your payment will go directly into your checking or savings account. The first month’s deposit would probably be a check (which could take as long as four weeks to receive), your next payment would be sent directly to your bank account. With direct Deposit your payment should be available to you the Wednesday or Thursday after payroll closes. Although some people are concerned about the safety of their money using Direct Deposit, this is the safest choice available. By choosing this option, no one can take your money out of your account. Thousands of providers successfully receive payments every month through this method. KeyBank Prepaid Card • This card would be issued to you and your child care payments would be deposited directly onto the card. The card works like a debit card, you can withdraw cash, make purchases at grocery stores and some department stores (Wal-Mark and Kmart), and withdraw cash from ATM machines (remember ATM’s charge a fee, which would reduce your amount). You would have access to your money within three days after payroll closes and this is the fastest way to get your payment. PLEASE SELECT ONLY ONE OF THE FOLLOWING PAYMENT OPTIONS: ❑ I acknowledge currently receive direct deposit and would like to continue. ❑ Direct Deposit ❑ New Colorado KeyBank Prepaid Card Based on your choice above, the proper payment form will be sent to you with your CCCAP fiscal agreement draft. Both forms will need to be completed and returned to your CCCAP county office. Provider Signature Date Provider Name (PLEASE PRINT) Social Security Number or Provider ID# LCHS 4220 (09/18) Provider Direct Deposit Enrollment Form For Colorado Cash Assistance Benefits ***PROVIDER NUMBER REQUIRED FOR ENTRY*** (if you are unsure of your provider number please reach out to your local county office) Child Care (CC) Xxxxxx/Adoptive (CW) (5+ digits) CBMS CW/TANF & AF-Burial (9 digit EFT Number) LEAP (LE) CORE, CASE (CW3) (5+ digits) CBMS Nursing Home (NH) (5+ digits) Name of person completing this section: Phone (include area code) ( ) - I am completing this form to: (please check one option only) ☐✔ Enroll in ACH Direct Deposit into my responsibility personal bank account ☐✔ Change my Direct Deposit banking information or ☐ Cancel Direct Deposit I (we) hereby authorize Colorado Department of Human Services (CDHS), to respect initiate credit entries, and if necessary, reverse any incorrect EFT credit entries made in error to the confidentiality bank account indicated below, in accordance with standard banking procedures, for payments related to the Colorado Electronic Benefit Transfer (EBT) Programs. Provider Name (or Business Name) Address City _ State Zip Phone Number (including area code) ( ) - Federal E.I.N. Number _ - OR Social Security Number _ ☐ Bank Account Information (please check one option only): Checking Account or ☐Savings Account Bank Account Number Bank Name City State Zip Bank Routing Number (9-digit) (Check with your bank to ensure that this number is correct for direct deposit) This agreement is to remain in effect until CDHS, has received written notification of student records its termination in such time and manner to afford CDHS a reasonable opportunity to act in on it. It is the responsibility of the vendor/provider to fill out and submit a professional manner in new Authorization Agreement to CDHS if the handling of student datavendor/provider changes or closes the account. I will ensure that confidential data, including personally identifiable information (PII) is not created, collected, stored, maintained, Provider/Vendor Signature Date Please return the completed form and voided check or disseminated in violation of state and federal laws. Furthermore, I agree bank letter to the following guidelines regarding the appropriate use of student data collected by myself or made available to me from other school or district employees: • I will comply with school district confidentiality policies, as well as state and federal confidentiality laws including Family Educational Rights and Privacy Act (FERPA): xxxx://xxx.xx.xxx/offices/OM/fpco/ferpa/, and the Children’s Online Privacy Protection Act (COPPA): xxxxx://xxx.xxx.xxx/enforcement/rules/rulemaking-regulatory-reform- proceedings/childrens-online-privacy-protection-rule • Student data will only be accessed for students for whom I have a legitimate professional need and will be used for the sole purpose of improving student achievement or ensuring student and school safety. • I understand that student specific data is never to be transmitted via email or as an email attachment unless the file is encrypted, password protected or PII has been redacted. • I will securely log in and out State EBT Program using one of the programs that store student specific datamethods below to begin receiving payments by direct deposit. I will not share my password nor Please keep password information in an accessible locationa copy of this form for your records. Any documents I create containing student specific data will be stored securely within the district network or within  Email: xxxx_xxx_xxxxxx@xxxxx.xx.xx (preferred method)  Fax: (000)000-0000  Mail: CDHS/EBT Program, 0000 Xxxxxxx Xx., 3rd Floor, Denver, Colorado 80203 Rev 08.23.2017 Formulario de inscripción de depósito directo del proveedor para beneficios de ayuda en efectivo de Colorado ***SE REQUIERE EL NÚMERO DE PROVEEDOR *** (si no está seguro del número de su proveedor comuníquese con la oficina local de su condado) Cuidado infantil (CC) Tutelar/adoptivo (CW) (5+ dígitos) CBMS CW/TANF y AF-Burial (entierro) (Número EFT de 9 dígitos) LEAP (LE) CORE, CASE (CW3) (5+ dígitos) Residencia de ancianos de CBMS (NH) (5+ dígitos) Nombre de la persona que llena esta sección: Teléfono (incluir el código de área) ( ) - Lleno este formulario para: (marque solo una opción) ☐ Inscribir el depósito directo ACH en mi cuenta bancaria personal ☐ Cambiar mi información bancaria de depósito directo o ☐ Cancelar el depósito directo Autorizo/autorizamos por este medio al Departamento de Servicios Humanos de Colorado (CDHS) a passworddar crédito, y si fuera necesario, reversar cualquier crédito incorrecto, mediante transferencia electrónica de fondos, (Electronic Funds Transfer, EFT) a la cuenta bancaria que se indica más abajo, de conformidad con los procedimientos bancarios convencionales, para pagos relacionados con los programas de transferencia electrónica de beneficios (Electronic Benefit Transfer, EBT) de Colorado. Nombre del proveedor (o nombre comercial) Dirección Ciudad Estado Código postal Número de teléfono (incluir el código de área) ( ) - E.I.N. (N.º de ident. el empleador) federal - O Número del seguro social ☐✔ Información de la cuenta bancaria (marque solo una opción): Cuenta bancaria o ☐Cuenta de ahorros Número de cuenta bancaria Nombre del banco Ciudad Estado Código postal Número de ruta y tránsito (9-protected environmentdígitos) (Consulte a su banco para asegurarse de que este número sea correcto para depósito directo) Este acuerdo seguirá vigente hasta que CDHS haya recibido la notificación por escrito de su terminación en tiempo y manera que dé a CDHS una posibilidad razonable de obrar en consecuencia. I will not store student specific data on any personal computer and/or external devices that are not password protectedEl proveedor/la empresa proveedora será responsable de llenar y presentar un nuevo acuerdo de autorización a CDHS si el proveedor/la empresa proveedora cambia o cierra la cuenta. Firma del proveedor/empresa proveedora Fecha Devuelva el formulario completado y un cheque anulado o una carta del banco al programa de EBT estatal mediante uno de los métodos que se indican a continuación para comenzar a recibir pagos por depósito directo. Guarde una copia de este formulario xxxx xxxxxxxxxx.  Correo electrónico: xxxx_xxx_xxxxxx@xxxxx.xx.xx (External devices include but are not limited to USBmétodo preferente)  Fax: (000)000-0000  Correo postal: CDHS/thumb drivesEBT Program, external hard drives0000 Xxxxxxx Xx., cell phones and tablets.) • I will not record any digital or online virtual learning or assessment sessions that would become part of a student's record. • Regardless of its format3rd Floor, I will treat all information with respect for student privacy. I will not leave student data in any form accessible or unattendedDenver, including information on a computer display or hard copy documents. • Any digital or hard copy records containing PII will be returned to the district office or school site when employment or job assignment has been completed or terminated. By signing below, I acknowledge, understand and agree to accept all terms and conditions of the Xxxxxx Xxxx Unified School District’s Student Data Confidentiality Agreement. Signature of Employee/Contractor Date Print Name Job Title TO TECHNOLOGY SERVICES AGREEMENT FOR CALIFORNIA EDUCATION CODE 49073.1 COMPLIANCE This Addendum No. is entered into between Xxxxxx Xxxx Unified School District (“District”) and (“Service Provider”) on .Colorado 80203

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRAXXX, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Xxxxxxx Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. I acknowledge my responsibility to respect THIS CALIFORNIA BROKER AGREEMENT (the confidentiality of student records and to act in a professional manner in the handling of student data. I will ensure that confidential data, including personally identifiable information (PII“Agreement”) is not createdmade as of the date written on the signature page (the “Effective Date”), collectedbetween , storedAspire General Insurance Services, maintainedLLC(DBA: Aspire Insurance Services) a Nevadalimited liability company, or disseminated in violation (hereinafter “Aspire”), with its principal place of state and federal laws. Furthermorebusiness located at 0000 Xxxxxx Xx., I agree to the following guidelines regarding the appropriate use of student data collected by myself or made available to me from other school or district employees: • I will comply with school district confidentiality policiesXxxxx X, as well as state and federal confidentiality laws including Family Educational Rights and Privacy Act (FERPA): xxxx://xxx.xx.xxx/offices/OM/fpco/ferpa/Xxxxxx Xxxxxxx, Xxxxxxxxxx 00000 and the Children’s Online Privacy Protection Act producer set forth on the signature page, with its principal place of business listed therein (COPPA): xxxxx://xxx.xxx.xxx/enforcement/rules/rulemaking-regulatory-reform- proceedings/childrens-online-privacy-protection-rule • Student data will only hereinafter “Broker”). Aspire and Broker may be accessed for students for whom I have a legitimate professional need referred to individually as “Party” and will be used for collectively as the sole purpose of improving student achievement or ensuring student and school safety. • I understand that student specific data is never to be transmitted via email or “Parties.” The Parties hereby agree as an email attachment unless the file is encrypted, password protected or PII has been redacted. • I will securely log in and out of the programs that store student specific data. I will not share my password nor keep password information in an accessible location. Any documents I create containing student specific data will be stored securely within the district network or within a password-protected environment. I will not store student specific data on any personal computer and/or external devices that are not password protected. (External devices include but are not limited to USB/thumb drives, external hard drives, cell phones and tablets.) • I will not record any digital or online virtual learning or assessment sessions that would become part of a student's record. • Regardless of its format, I will treat all information with respect for student privacy. I will not leave student data in any form accessible or unattended, including information on a computer display or hard copy documents. • Any digital or hard copy records containing PII will be returned to the district office or school site when employment or job assignment has been completed or terminated. By signing below, I acknowledge, understand and agree to accept all terms and conditions of the Xxxxxx Xxxx Unified School District’s Student Data Confidentiality Agreement. Signature of Employee/Contractor Date Print Name Job Title TO TECHNOLOGY SERVICES AGREEMENT FOR CALIFORNIA EDUCATION CODE 49073.1 COMPLIANCE This Addendum No. is entered into between Xxxxxx Xxxx Unified School District (“District”) and (“Service Provider”) on .follows:

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRAXXX, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Xxxxxxx Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. I acknowledge my responsibility Submit completed form to: Kent State University Accounts Payable XX Xxx 0000 Xxxx XX 00000-0000 or xxxxxxxx@xxxx.xxx Vendors are encouraged to respect the confidentiality of student records and to act in a professional manner in the handling of student datause encryption when submitting this form via email. I will ensure that confidential dataKENT STATE UNIVERSITY Accounts Payable Direct Deposit Enrollment Form Initial Authorization ‐ COMPLETE SECTIONS A, including personally identifiable information (PII) is not created, collected, stored, maintained, or disseminated in violation of state and federal laws. Furthermore, I agree to the following guidelines regarding the appropriate use of student data collected by myself or made available to me from other school or district employees: • I will comply with school district confidentiality policies, as well as state and federal confidentiality laws including Family Educational Rights and Privacy Act (FERPA): xxxx://xxx.xx.xxx/offices/OM/fpco/ferpa/B, and the Children’s Online Privacy Protection Act (COPPA): xxxxx://xxx.xxx.xxx/enforcement/rules/rulemaking-regulatory-reform- proceedings/childrens-online-privacy-protection-rule • Student data will only be accessed for students for whom I have a legitimate professional need and will be used for the sole purpose of improving student achievement or ensuring student and school safety. • I understand that student specific data is never to be transmitted via email or as an email attachment unless the file is encrypted, password protected or PII has been redacted. • I will securely log in and out of the programs that store student specific data. I C. Incomplete forms will not share my password nor keep password be processed Change in Vendor Contact Information ‐ COMPLETE SECTIONS A, B, and D. Previous information in an accessible locationmust be provided for verification purposes. Any documents I create containing student specific data will be stored securely within the district network or within a password-protected environment. I Incomplete forms will not store student specific data on any personal computer and/or external devices that are not password protectedbe processed. (External devices include but are not limited to USB/thumb drivesChange in Financial Institution Information ‐ COMPLETE SECTIONS A, external hard drivesC, cell phones and tablets.) • I E. Previous information must be provided for verification purposes. Incomplete forms will not record any digital or online virtual learning or assessment sessions that would become part of a student's record. • Regardless of its format, I will treat all information with respect for student privacy. I will not leave student data in any form accessible or unattended, including information on a computer display or hard copy documents. • Any digital or hard copy records containing PII will be returned to the district office or school site when employment or job assignment has been completed or terminated. By signing below, I acknowledge, understand and agree to accept all terms and conditions of the Xxxxxx Xxxx Unified School District’s Student Data Confidentiality Agreement. Signature of Employee/Contractor Date Print Name Job Title TO TECHNOLOGY SERVICES AGREEMENT FOR CALIFORNIA EDUCATION CODE 49073.1 COMPLIANCE This Addendum No. is entered into between Xxxxxx Xxxx Unified School District (“District”) and (“Service Provider”) on processed.

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Xxxxxxx uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. I acknowledge my responsibility NOTICE TO HOUSING CHOICE VOUCHER OWNERS AND MANAGERS REGARDING THE VIOLENCE AGAINST WOMEN ACT (VAWA) A federal law that went into effect in 2013 protects individuals who are victims of domestic violence, dating violence, sexual assault, and stalking. The name of the law is the Violence against Women Act, or “VAWA.” This notice explains your obligations under VAWA. Protections for Victims You cannot refuse to respect rent to an applicant solely because he or she is a victim of domestic violence, dating violence, sexual assault, or stalking. You cannot evict a tenant who is the confidentiality victim of student records domestic violence, dating violence, sexual assault, or stalking based on acts or threats of violence committed against the victim. Also, criminal acts directly related to the domestic violence, dating violence, sexual assault, or stalking that are caused by a household member or guest cannot be cause for evicting the victim of the abuse. Permissible Evictions You can evict a victim of domestic violence, dating violence, sexual assault, or stalking if you can demonstrate that there is an actual and imminent (immediate) threat to act in a professional manner in other tenants or employees at the handling of student data. I will ensure that confidential data, including personally identifiable information (PII) property if the victim is not createdevicted. Also, collected, stored, maintained, you may evict a victim for serious or disseminated in violation of state and federal laws. Furthermore, I agree to the following guidelines regarding the appropriate use of student data collected by myself or made available to me from other school or district employees: • I will comply with school district confidentiality policies, as well as state and federal confidentiality laws including Family Educational Rights and Privacy Act (FERPA): xxxx://xxx.xx.xxx/offices/OM/fpco/ferpa/, and the Children’s Online Privacy Protection Act (COPPA): xxxxx://xxx.xxx.xxx/enforcement/rules/rulemaking-regulatory-reform- proceedings/childrens-online-privacy-protection-rule • Student data will only be accessed for students for whom I have a legitimate professional need and will be used for the sole purpose of improving student achievement or ensuring student and school safety. • I understand that student specific data is never to be transmitted via email or as an email attachment unless the file is encrypted, password protected or PII has been redacted. • I will securely log in and out of the programs that store student specific data. I will not share my password nor keep password information in an accessible location. Any documents I create containing student specific data will be stored securely within the district network or within a password-protected environment. I will not store student specific data on any personal computer and/or external devices repeated lease violations that are not password protectedrelated to the domestic violence, dating violence, sexual assault, or stalking. (External devices include but You cannot hold a victim of domestic violence, dating violence, sexual assault, or stalking to a more demanding standard than you hold tenants who are not limited victims. Removing the Abuser from the Household You may bifurcate (split) the lease to USB/thumb drivesevict a tenant who has committed criminal acts of violence against family members or others, external hard driveswhile allowing the victim and other household members to stay in the unit. If you choose to remove the abuser, cell phones and tablets.) • I will you may not record any digital or online virtual learning or assessment sessions that would become part of a student's record. • Regardless of its format, I will treat all information with respect for student privacy. I will not leave student data in any form accessible or unattended, including information on a computer display or hard copy documents. • Any digital or hard copy records containing PII will be returned take away the remaining tenants’ rights to the district office unit or school site when employment or job assignment has been completed or terminatedotherwise punish the remaining tenants. By signing belowIn removing the abuser from the household, I acknowledgeyou must follow federal, understand state, and agree to accept all terms and conditions of the Xxxxxx Xxxx Unified School District’s Student Data Confidentiality Agreement. Signature of Employee/Contractor Date Print Name Job Title TO TECHNOLOGY SERVICES AGREEMENT FOR CALIFORNIA EDUCATION CODE 49073.1 COMPLIANCE This Addendum No. is entered into between Xxxxxx Xxxx Unified School District (“District”) and (“Service Provider”) on local eviction procedures.

Privacy Act Notice. Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Xxxxxx MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Xxxxxxx uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information. List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished. Circle the minor’s name and furnish the minor’s SSN. DEPARTMENT OF HUMAN SERVICES Child Care Assistance Program 0000 Xxxx Xxxxxx Xxxxx Xxxx Xxxxxxx, CO 80524 (000) 000-0000 Fax: (000) 000-0000 PAYMENT OPTION Dear Qualified Exempt Non-Licensed Child Care Provider, You have a choice of how you will receive your child care payments. Below are your options and a little information about each choice. Direct Deposit • Your payment will go directly into your checking or savings account. The first month’s deposit would probably be a check (which could take as long as four weeks to receive), your next payment would be sent directly to your bank account. With direct Deposit your payment should be available to you the Wednesday or Thursday after payroll closes. Although some people are concerned about the safety of their money using Direct Deposit, this is the safest choice available. By choosing this option, no one can take your money out of your account. Thousands of providers successfully receive payments every month through this method. KeyBank Prepaid Card • This card would be issued to you and your child care payments would be deposited directly onto the card. The card works like a debit card, you can withdraw cash, make purchases at grocery stores and some department stores (Wal-Mark and Kmart), and withdraw cash from ATM machines (remember ATM’s charge a fee, which would reduce your amount). You would have access to your money within three days after payroll closes and this is the fastest way to get your payment. PLEASE SELECT ONLY ONE OF THE FOLLOWING PAYMENT OPTIONS:  I acknowledge currently receive direct deposit and would like to continue.  Direct Deposit  New Colorado KeyBank Prepaid Card Based on your choice above, the proper payment form will be sent to you with your CCCAP fiscal agreement draft. Both forms will need to be completed and returned to your CCCAP county office. Provider Signature Date Provider Name (PLEASE PRINT) Social Security Number or Provider ID# LCHS 4220 (09/18) Provider Direct Deposit Enrollment Form For Colorado Cash Assistance Benefits ***PROVIDER NUMBER REQUIRED FOR ENTRY*** (if you are unsure of your provider number please reach out to your local county office) Child Care (CC) Xxxxxx/Adoptive (CW) (5+ digits) CBMS CW/TANF & AF-Burial (9 digit EFT Number) LEAP (LE) CORE, CASE (CW3) (5+ digits) CBMS Nursing Home (NH) (5+ digits) Name of person completing this section: Phone (include area code) ( ) - I am completing this form to: (please check one option only) ☐✔ Enroll in ACH Direct Deposit into my responsibility personal bank account ☐✔ Change my Direct Deposit banking information or ☐ Cancel Direct Deposit I (we) hereby authorize Colorado Department of Human Services (CDHS), to respect initiate credit entries, and if necessary, reverse any incorrect EFT credit entries made in error to the confidentiality bank account indicated below, in accordance with standard banking procedures, for payments related to the Colorado Electronic Benefit Transfer (EBT) Programs. Provider Name (or Business Name) Address City _ State Zip Phone Number (including area code) ( ) - Federal E.I.N. Number _ - OR Social Security Number _ ☐ Bank Account Information (please check one option only): Checking Account or ☐Savings Account Bank Account Number Bank Name City State Zip Bank Routing Number (9-digit) (Check with your bank to ensure that this number is correct for direct deposit) This agreement is to remain in effect until CDHS, has received written notification of student records its termination in such time and manner to afford CDHS a reasonable opportunity to act in on it. It is the responsibility of the vendor/provider to fill out and submit a professional manner in new Authorization Agreement to CDHS if the handling of student datavendor/provider changes or closes the account. I will ensure that confidential data, including personally identifiable information (PII) is not created, collected, stored, maintained, Provider/Vendor Signature Date Please return the completed form and voided check or disseminated in violation of state and federal laws. Furthermore, I agree bank letter to the following guidelines regarding the appropriate use of student data collected by myself or made available to me from other school or district employees: • I will comply with school district confidentiality policies, as well as state and federal confidentiality laws including Family Educational Rights and Privacy Act (FERPA): xxxx://xxx.xx.xxx/offices/OM/fpco/ferpa/, and the Children’s Online Privacy Protection Act (COPPA): xxxxx://xxx.xxx.xxx/enforcement/rules/rulemaking-regulatory-reform- proceedings/childrens-online-privacy-protection-rule • Student data will only be accessed for students for whom I have a legitimate professional need and will be used for the sole purpose of improving student achievement or ensuring student and school safety. • I understand that student specific data is never to be transmitted via email or as an email attachment unless the file is encrypted, password protected or PII has been redacted. • I will securely log in and out State EBT Program using one of the programs that store student specific datamethods below to begin receiving payments by direct deposit. I will not share my password nor Please keep password information in an accessible locationa copy of this form for your records. Any documents I create containing student specific data will be stored securely within the district network or within  Email: xxxx_xxx_xxxxxx@xxxxx.xx.xx (preferred method)  Fax: (000)000-0000  Mail: CDHS/EBT Program, 0000 Xxxxxxx Xx., 3rd Floor, Denver, Colorado 80203 Rev 08.23.2017 Formulario de inscripción de depósito directo del proveedor para beneficios de ayuda en efectivo de Colorado ***SE REQUIERE EL NÚMERO DE PROVEEDOR *** (si no está seguro del número de su proveedor comuníquese con la oficina local de su condado) Cuidado infantil (CC) Tutelar/adoptivo (CW) (5+ dígitos) CBMS CW/TANF y AF-Burial (entierro) (Número EFT de 9 dígitos) LEAP (LE) CORE, CASE (CW3) (5+ dígitos) Residencia de ancianos de CBMS (NH) (5+ dígitos) Nombre de la persona que llena esta sección: Teléfono (incluir el código de área) ( ) - Lleno este formulario para: (marque solo una opción) ☐ Inscribir el depósito directo ACH en mi cuenta bancaria personal ☐ Cambiar mi información bancaria de depósito directo o ☐ Cancelar el depósito directo Autorizo/autorizamos por este medio al Departamento de Servicios Humanos de Colorado (CDHS) a passworddar crédito, y si fuera necesario, reversar cualquier crédito incorrecto, mediante transferencia electrónica de fondos, (Electronic Funds Transfer, EFT) a la cuenta bancaria que se indica más abajo, de conformidad con los procedimientos bancarios convencionales, para pagos relacionados con los programas de transferencia electrónica de beneficios (Electronic Benefit Transfer, EBT) de Colorado. Nombre del proveedor (o nombre comercial) Dirección Ciudad Estado Código postal Número de teléfono (incluir el código de área) ( ) - E.I.N. (N.º de ident. el empleador) federal - O Número del seguro social ☐✔ Información de la cuenta bancaria (marque solo una opción): Cuenta bancaria o ☐Cuenta de ahorros Número de cuenta bancaria Nombre del banco Ciudad Estado Código postal Número de ruta y tránsito (9-protected environmentdígitos) (Consulte a su banco para asegurarse de que este número sea correcto para depósito directo) Este acuerdo seguirá vigente hasta que CDHS haya recibido la notificación por escrito de su terminación en tiempo y manera que dé a CDHS una posibilidad razonable de obrar en consecuencia. I will not store student specific data on any personal computer and/or external devices that are not password protectedEl proveedor/la empresa proveedora será responsable de llenar y presentar un nuevo acuerdo de autorización a CDHS si el proveedor/la empresa proveedora cambia o cierra la cuenta. Firma del proveedor/empresa proveedora Fecha Devuelva el formulario completado y un cheque anulado o una carta del banco al programa de EBT estatal mediante uno de los métodos que se indican a continuación para comenzar a recibir pagos por depósito directo. Guarde una copia de este formulario xxxx xxxxxxxxxx.  Correo electrónico: xxxx_xxx_xxxxxx@xxxxx.xx.xx (External devices include but are not limited to USBmétodo preferente)  Fax: (000)000-0000  Correo postal: CDHS/thumb drivesEBT Program, external hard drives0000 Xxxxxxx Xx., cell phones and tablets.) • I will not record any digital or online virtual learning or assessment sessions that would become part of a student's record. • Regardless of its format3rd Floor, I will treat all information with respect for student privacy. I will not leave student data in any form accessible or unattendedDenver, including information on a computer display or hard copy documents. • Any digital or hard copy records containing PII will be returned to the district office or school site when employment or job assignment has been completed or terminated. By signing below, I acknowledge, understand and agree to accept all terms and conditions of the Xxxxxx Xxxx Unified School District’s Student Data Confidentiality Agreement. Signature of Employee/Contractor Date Print Name Job Title TO TECHNOLOGY SERVICES AGREEMENT FOR CALIFORNIA EDUCATION CODE 49073.1 COMPLIANCE This Addendum No. is entered into between Xxxxxx Xxxx Unified School District (“District”) and (“Service Provider”) on .Colorado 80203