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01/08/2007 16:48 FAx f�0021002 <br /> . • <br /> Sea13.04 RIGFTTS OR SUB,�CTS OF DwTA <br /> Subd.1, Type of daw. The righ�s of individusl on whom�he dsw is swred or ro be acored shall be as set forth m thia sectian. <br /> Subd.2. Infbrma�ion required to bo given individusl,An individual oaked W avpply p�vate arconfidendal data conceming himselfsha�l be <br /> jnfomicd ofi (s)the pwpose and inDended uee of�he requee�ed ds�wi�hin the collxtins eta[e agency,policical eubdivieion,0�3[atewide Syslem;(b) <br /> whe�hor he may rcfusc or ia lcgally rcquircd to supply�Nc requwtcd dau;(c)any knovm crnuequcnce ari�ing fFom hls supplying or isfuaing to supply <br /> privace or cunfiden�ial dsra;and(d)�he�dcn�iry ofothcr persona or en�i�iea surhonzed by srare or fodero�law�o recdve�he da�a,This nquironunt ehal] <br /> not apply when an individux)is axkeJ tu aupply investibuuvo ddtu,pursunnt�o sec[ion 13,62,eubdiviaion 5,W a Iaw enforc�me��office[, <br /> Tlfe commissioner of ravenue msv nlace�he ne�ice rcnuired�nd�r thia nubdivision in�he indiv;dLal income enx or ero9emr tax retimd <br /> inatrucdons in6�ead of on chose forme. <br /> Subd.3. Acceaa ro daca by indiv�dual.Upon requesc[o a roeponsible authoriry,an individual ghall be infonf�edwhe[herhe is�he Subject of <br /> swred ds�a on mdividuals,and whed�er ic is eleseiFied as public,privace or canfidenual. Upon hig fuN�er requegt,an Ind'Ivldual who is rhe�ubject of <br /> swrcd pnvau or public dara on ind�vidual9 shell bc ehown�he da�a wi[hout any chargc[o hiro and,if he des�ros,shsll be infortned of�he conunt and <br /> meaning of sha�data, After an individual ha�bcen ghown tl�c prjvate da�a and informed of iu meening,the dete need not be disclosed to him for 9ix <br /> mon�s�hereaftcr unless s dispuu oe action pursuan�co�is secdoo is pending or additional daw ua the indi�idual has been collected or erea�ed, The <br /> re8punaibla auchoriry shrll pruv�cle copies of the privute or public dstx upon roquest by she individusl aubjec�of�he data, 'I'he responsible authoriry <br /> mey requiro the roquesting person co pay�he actusl co6ts af malong,cenifying,and compiling�he copiCs. <br /> The reaponsible authariry 9hall comply immcdia�cly,ifpossible,virnh any reques�made putsuao[[o this subdivision,orwichin fivc days of <br /> �ha deC�uf[hb requtst,excluding SnNrdays,Sundays end legnl holidrys,if irtunediate campJiance ia nocpassiblc, Ifhc csn�ot cornply wi�h�he request <br /> within that time.he ahall ao inform the indiv�dual,and mey he�e an addiiional five days wid�ie whiah to comply wi�h�ho reqvesR excluding Soturdnys, <br /> Sundeys snd legal holidays, <br /> Subd,d, Prueedurc when Jalu is oot sccura�e or complrta An iculividurl mny wnteat�he accuracy or complaoness of public ar privnu dam <br /> concerning himsel£ To exeroiu shis righ�,an individual shall notiYy in ariting the ro5pon9ible audlwity doBCnbing ehe nature of the disagrtement.Thc <br /> responaible au�horiry shall wichin 30 days ei�er: (a)correc�rhe daw Yound so be inaccucek or incomple�e and aaemp�w noufy pa�s recipien�s of <br /> maccurafe or incornpltte daw,including recipien�s ne�ned Fry�he individusl;or(b)oadfy the iodividual rhat he belicvcs thc daraw be correcc.D�tn in <br /> dispute Bhall be disclosed only if the iodividual's sra�emeac ofdi9agreement ie included aith�ho disclosed daw, <br /> The dec¢rmina�ion of�he responsible au�horiry may be appealed pursuan�co cha provisions of the administradve procedurc ac�rcle�ieg w <br /> con�esced casea. <br /> PATA PRIVACY ADVISORY <br /> In accordance with M.S, 13,04,Subd.2,"Rights ofsubjects of data",we would like to infoTmyou[hai�ourrequcst <br /> for a permic or licens�from the Ciry of Orono or an� of i�s deparcmens�may require you to fumish cenain priva�e or <br /> confidential information. <br /> You are no�ified chat; <br /> 1, The information you furnish will be used to determine your qualificavon fot the permit or license <br /> rcqucstcd. <br /> 2. You may refuse to supply data,but refusal may reyuire that the Ciry deny the permit or license, <br /> 3. The informacion may be shared with ocher local, state or federal agencies w the extani neeessary to <br /> process che pe�mic or lieense, <br /> 4, If yow requesced pemtit or lieense requires Council action to approve,some information may become <br /> public. <br /> 5. You have certain rights under M.S. 13.04(available upon request)to review private deta on yourself, <br /> G. Your full name is�equired to process this applicaGon or poimit. <br /> �irat �y u� � Mlddle � �� <br /> Ji� � ����d�✓ <br /> Addreas <br /> 6o2d Go�INC�-_�� �-� <br /> Cify A-., t � ���� 9tete Zip �� Phone �� ��'�' <br /> ��rv� �''�h �6�1 <br /> Y understand my rlghts state ovc� <br /> SiRnature <br /> �jx t���'� ��"+' ,,,'��"�•`��, �'��Y �, 32 <br /> '„ ,,,,.�' �',�'�,r �{ ���� �:'R�,,, <br /> ,nP�'I,a���SM+'dM���� �u:� <br />