1. 1. Name of Agency Subdivision of agency maintaining

   system of records

   Title and business address of agency official responsible for system of records.

2. 2. Indicate procedures by which a data subject may gain access to personal information pertaining to such data subject in the system of records and the procedures by which a data subject may seek to amend or correct its contents (where appropriate, include legal reference to procedures and attached procedures as appendix).
3. 3. Identify categories of persons on whom records will be maintained in the system of records.
4. 4. Provide approximate number of persons about whom records will be maintained in the system of records.
5. 5. Describe or provide legal reference to policies governing retention and timely disposal of information within the system of records in accordance with law:

6. 6. The system of records will be maintained (mark with “X”):

   ____ manually, ____by automated data system, ____ both

7. 7. List below as indicated (include appendix if necessary):

   in column (a), the categories of information which will be collected and maintained in the system of records;

   in column (b), the purposes for which each category of information within the system of records will be collected and maintained;

   in column (c), the general or specific statutory authority for the collection, maintenance and disclosure of each category of information within the system of records;

   in column (d), each and every source for each category of information within the system;

   in column (e), the disclosures of personal information within the system of records that the agency will regularly make for each category of information;

   in column (f), the authority for regular disclosures identified in column (e).

8. (a) categories of information (b) purposes

   _____________ _____________

   _____________ _____________

   _____________ _____________

   _____________ _____________

   _____________ _____________

9. (c) statutory authority (d) sources

   _____________ _____________

   _____________ _____________

   _____________ _____________

   _____________ _____________

   _____________ _____________

10. (e) regular disclosures (f) authority for each disclosure listed in column (e)

    _____________ _____________

    _____________ _____________

    _____________ _____________

    _____________ _____________

    _____________ _____________

The form of the privacy impact statement shall consist of the following:

PRIVACY IMPACT STATEMENT

Prepared pursuant to Public Officers Law, § 93

Personal Privacy Protection Law

__________________

Name of System of Records