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�' 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 conceming himseif shall be informed of: (a)the purpose and intended use of the requested data within the collecting state agency,pol itical subdivision,or statewide system;(b) whether he may refuse or is►egally required to supply the requested data;(c)any known consequence arising from his supptying or refusing to supply private or confidenual data;and(d)the identity of other persons or entities authorized by state or federal law to receive the data. This requirement shall not apply when an individual is asked to supply imestigative data,pursuant to section I 3.82,subdivision 5,to a law enforcement officer. The commissioner of revenue mav place the notice required under t} instructions instead of on those forms. / (/I/ � � ��J� �.�"'�� fi L� Subd.3. Access to data by individual. Upon request to a responsible a „�,,_s e.,�,/t�� stored data on individuals,and whether it is classified as public,private or confidi �/�if�� f �� stored private or public data on individuals shall be shown the data without any cl /+� ,4.,_ meaning of that data. After an individual has been shown the private data and inf /1�!� �� ^ C,��`�� / months thereafter unless a dispute or action parsuant to this section is pending or� /{�ii�i responsible authoriry shall provide copies of the private or public data upon requ� �j / S d�C may require the requesting person to pay the actual costs of making,ceRifying,a ,,.�0 Z�N� � The responsible authority shall comply immediately,if possible,with a �,I' the date ofthe request,excluding Saturdays,Sundays and legal holidays,ifimmedi �� S `,,�M � "'� within that time,he shall so inform the individual,and may have an additional five ^� Sundays and legal holidays. ��1�►/� 1 Q�1SQ r V LS ��L, �r J Subd.4. Procedure when data is not accurate or complete. An individua ,y.�� S �� concerning himself. To exercise this right,an individual shall notify in writing the n I��r`9' "D.�(S � � �` responsible authority shall within 30 days either. (a)correct the data found to be �/� inaccurate or incomplete data,including recipienu named by the individual;or(b)� )�`�'�/[-�JJ . � • dispute shall be disclosed only if the individual's statement of disagreement is incl �' /�� C The determination ofthe responsible authority may be appealed pursua . contested cases. � DATA PRIVACY In accordance 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 depaRments 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 permit or license. 3. The information may be shared with other local, state or federal agencies to the extent necessary to process the permit or license. 4. lf your requested permit or license requires Councii 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. �iA►1 1A First Middle Lest I�1 � IA�oo�S�?,n�3 � • Address ��o�. VI�I►� ��C, gst� 3, C�ty State Zip Phone O e ! 1 I understand m rights as stated above. ._ � • Signature � C Reset Form 32 Y' `