(i) the name of the subdivision of the department requesting the personal information and the name or title of the system of records in which such information will be maintained;

(ii) the title, business address and telephone number of the department official who is responsible for the system of records;

(iii) the authority granted by law which authorizes the collection and maintenance of personal information;

(iv) the effects, if any, upon such data subject of not providing all or part of the information requested;

(v) the principal purpose or purposes for which information is to be collected; and

(vi) the uses which may be made of the information pursuant to paragraphs (b), (c), (f) of subdivision 1 of section 96 of the Public Officers Law.