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i . � ' o- Sec.13.04 RIGHTS OF SUBJECTS OF DATA Subd. 1. Type of data. The rights of individual on whom the data is stored or to be stored shall be as set forth in this section. Subd.2. Information required to be given individual. An individual asked ro supply private or confidential data concerning himself sha►I be informed of: (a)the�rpose and intended use of the requested data within the collecting state agency,political subdivision,or statewide system;(b)whether he may refuse or is legaily required to supply the requested data;(c)any known consequence arising from his supplying or refusing ro supply private or confidential data;and(d)the idendty of other persons or entides authorized by state or federal law to receive the data. This requirement shall not apply when an individual is asked to supply investigative data, pursuant to section 13.82, subdivision 5, to a law enforcement officer. The commissioner of revernie mav nlace the notice reauired under this subdivision in the individual income tax or nronertv tax refund insuucaons instead of on those forms. Subd. 3. Access to data by individual. Upon request to a responsible authority,an individual shall be informed whether he is the subject of stored data on individuals,and whether it is classified as public,private or confidendal. Upon his further request,an individual who is�e subject of stored private or public data on individuals shall be shown the data without any charge to him and,if he desires,shall be infortned of the content and meaning of that data. After an individual has been shown the private data and informed of its meaning,the data need not be disclosed to him for six months thereafter unless a dispute or acdon pursuant to dus section is pe�ing or additional data on ihe individual has been collected or created. The responsible authoriry shall provide copies of the private or public data upon request by the individual subject of the data. The responsible authority may require the requesting person to pay the actual costs of making,certifying,and compiling the copies. The responsible audioriry shall comply immediately,if possible,with any request made pursuant to this subdivision,or within five days of the date of the request,excluding Saturdays,Sundays and legal holidays,if immediate compliance is not possible. If he cannot comply with the request within that time,he shall so inform the individual,and may have an addidonal five days within which to comply with the request, excluding Saturdays,Sundays and legal holidays. Subd.4. Procedure when data is not accurate or complete. An individual may contest the accuracy or compieteness of public or private data conceming himself. To exercise this right,an individual shall notify in writing the responsible authority describing the nature of the disagreement. The responsible authoriry shall within 30 days either: (a)correct the data found ro be inaccurate or incomplete and attempt to notify past recipients of inaccurate or incomplete data,icc�luding recipients named by the individual;or(b)notify the individual that he believes the dara to be correct. Data in dispute shall be disclosed only if the individual's statement of disagreement is included with the disclosed data. T'he detemvnation of the responsible authority may be appealed pursuant to the provisions of the administrative procedure act relating to contested cases. �ATA PRIVACY ADVISORY In accordanee with M.S. 13.04, Subd.2, "Rights of subjects of data", we would like to inform you that your' ` request for a permit or license from the City of Orono or any of its departments may require you to furnish certain private or confidential information. You are notified that: 1. The information you furnish will be used to determine your qualification for the permit or license requested. 2. You may refuse to supply data, but refusal may require that the City deny the pemut or license. 3. The information may be shued with other local, state or federal agencies to the extent necessary to process the permit or license. 4. If your requested permit or license requires Council action to approve, some information may become public. 5. You have certain rights under M.S. 13.04(available upon request)to review private data on yourself. 6. Your full name is required to process this application or permit. �,,v✓~C15 � I�F��vS - First Middle Last Z-1� � `�'1��1�1 cJ � Address ".� a��.►z�-� r�� s��I �-1"7�— i�l� Ciry State Zip Phone I understand my rights as stated above. 1�,�O 2��---� s�gnacure 6