Clean Mobility Voucher Pilot Program
CONFIDENTIALITY STATEMENT
As an authorized representative and/or officer of the organization named below, I warrant my organization and its employees will not disclose and will keep confidential any documents, diagrams, Personally Identifiable Information ( see next page for the definition of PII), and information storage media (i.e., databases, cloud storage, etc.) made available to us by the State, the Program Administrator, or community members for the purpose of implementing the Clean Mobility Voucher Pilot Program Voucher Agreement (Voucher Agreement) or in conjunction with any sub-contract agreement arising there from. No obligations in this Confidentiality Statement, however, prevents me or another representative of the organization named below from producing documents or information that are legally compelled under applicable law, including but not limited to a valid subpoena or California Public Records Act Request. If the Awardee believes disclosure may be required under the California Public Records Act or other law, the Awardee shall first give the State and Program Administrator written notice of the intent to disclose plus fourteen (14) days after receipt of the written notice to seek an order preventing disclosure from a court of competent jurisdiction.
I warrant that only those employees who are authorized and required to use such materials will have access to them and that they will sign confidentiality statements at least as restrictive as this one applicable to the organization named below.
I further warrant that all PII provided by the State, the Program Administrator or community members in conjunction with the Voucher Agreement will be physically and/or electronically destroyed once the information is no longer necessary for the implementation to meet the Voucher Agreement requirements. I will include a letter attesting to documenting the destruction of such PII to the Program Administrator as part of the completion of the project milestones. Failure to so comply will subject this organization to potential liability, including all damages to the State and third parties. I authorize the State and Program Administrator to inspect and verify compliance with this statement.
Signature of Responsible Party Date
Typed Name of Responsible Party
Typed Name of Organization
Exhibit H
For purposes of this confidentiality statement, Personally Identifiable Information (PII) includes but is not limited to an individual’s:
• Social Security number
• Driver license or state-issued ID number
• Military ID number
• Passport number
• Credit card (or debit card) number, CVV2, and expiration date • Financial account numbers (with or without access codes or passwords) • Customer account numbers
• Unlisted telephone numbers
• Date or place of birth
• Mother’s maiden name
• PINs or passwords
• Password challenge question responses
• Account balances or histories
• Wage & salary information
• Tax filing status
• Biometric data that can be used to identify an individual, including finger or voice prints
• Digital or physical copies of handwritten signature
• E-mail addresses
• Medical record numbers
• Vehicle identifiers and serial numbers, including license plate numbers • Medical histories
• National or ethnic origin
• Religious affiliation(s)
• Physical characteristics (height, weight, hair color, eye color, etc.) • Insurance policy numbers
• Credit or payment history data
• Full face photographic images and any comparable images • Certificate/license numbers
• Internet Protocol (IP) address numbers
Geolocation or physical address
Clean Mobility Voucher Pilot Program
CONFIDENTIALITY AGREEMENT
Failure to comply and return this attachment will cause your voucher agreement to be cancelled. Each key staff must read, agree, sign, date and submit this completed form (attach additional copies as needed).
The undersigned agrees to:
1. Observe complete confidentiality with respect to California Air Resources Board (CARB or State), Program Administrator, or Personally Identifiable Information (see next page for definition of PII) from community members,
including without limitation, agreeing not to disclose or otherwise permit access to such information or data developed or collected pursuant to the Clean Mobility Voucher Pilot Program by any person or entity in any manner unless such disclosure is required by law or legal process.
2. Acknowledge the confidential nature of such information or data developed or collected pursuant to the Clean Mobility Voucher Pilot Program and understand and agree that I am prohibited from copying or revealing, for any purpose whatsoever, the contents of such information or any part thereof, or from taking any action otherwise prohibited under this section.
3. Not use or sell such information or data developed or collected pursuant to the Clean Mobility Voucher Pilot Program or any part thereof in the performance of services to others or for the benefit of any person or entity in any form whatsoever whether gratuitously or for valuable consideration, except as permitted under this agreement.
4. Notify the State and Program Administrator promptly and in writing of the circumstances surrounding any possession, use or knowledge of such information or data developed or collected pursuant to the Clean Mobility Voucher Pilot Program or any part thereof, by any person other than those authorized by this document.
5. Treat all information, data, deliverables, and work products developed or collected pursuant to the Clean Mobility Voucher Pilot Program as confidential. All information, data, deliverables, and work products cannot be disclosed in any form to any third party without the Program Administrator or CARB’s written consent except when required by law or legal process.
6. Not use, without CARB or Program Administrator written approval, any materials provided by CARB or Program Administrator for any purpose other than performing the agreed upon services.
7. Notwithstanding anything to the contrary, this agreement does not restrict the signatory from sharing information with its employees, agents, and service providers to the extent necessary to perform the agreed upon services, and only
for this limited purpose. Nor does this agreement prohibit the disclosure of information that is otherwise publicly known or becomes publicly known through no wrongful action or inaction of the signatory or his or her organization.
Signature Date
Print Name Project Title
For purposes of this confidentiality agreement, Personally Identifiable Information (PII) includes but is not limited to an individual’s:
• Social Security number
• Driver license or state-issued ID number
• Military ID number
• Passport number
• Credit card (or debit card) number, CVV2, and expiration date • Financial account numbers (with or without access codes or passwords) • Customer account numbers
• Unlisted telephone numbers
• Date or place of birth
• Mother’s maiden name
• PINs or passwords
• Password challenge question responses
• Account balances or histories
• Wage & salary information
• Tax filing status
• Biometric data that can be used to identify an individual, including finger or voice prints
• Digital or physical copies of handwritten signature
• E-mail addresses
• Medical record numbers
• Vehicle identifiers and serial numbers, including license plate numbers • Medical histories
• National or ethnic origin
• Religious affiliation(s)
• Physical characteristics (height, weight, hair color, eye color, etc.) • Insurance policy numbers
• Credit or payment history data
• Full face photographic images and any comparable images • Certificate/license numbers
• Internet Protocol (IP) address numbers
Geolocation or physical address