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APR. 12. 2005 2: 50PM COLDWELL BANKER NO. 538 P. 5 <br /> SmI3.04 RIGH73 OF 5UI3.TiE:C'A'S OF DATA <br /> Subd.1. Type of data. The rights of individual on whom the data is stored or to be stored steal be as set ft$in this aaTicn. <br /> Subd.2. Information required to be given individual.An individual asked to supply private or confidential data nom ming himself shall be <br /> idformed of (a)the purpose and intended use of the requested data within the collecting state agency,polkical subdivision,or statewide syatam;(b) <br /> whathw he may refuse or is lcpVly rarAed to supply the requested data;(c)Sty imam aansequenee arising fs m his aupplybg or rchnigS to supply <br /> privatmoreonfiidentisl data;and(d)The identity ofodterpmons or entities audwiaedbystatsccfede ml lawtoreceim6edara.'chis requirement shall <br /> not apply when an individual is asked to supply invadptive data,pursuant to section 13.82,subdivision 5,to a law enforcemax oflieer. <br /> The rnissiener of revene►e may elsee the netiee reeWM ceder rhes Subdivision in the individual income IM pt m=jty ta:rcftmd <br /> jpgalogg instead of on those forms. <br /> Subd.3.Access io data by individual. Upon request w a respowfale au0hority,an individual shall be Ithnned whtadw be is the subject of <br /> stored data m Wividuob.and whWwit b classic W as public.private cr coofWondg Upm bis untrue request,an individual who b the subject of <br /> stored private or public data on individuals shall be down do don widout any charge to him"tf he desires.shall be informed of due content and <br /> meaning of that data. Attar an individual bas been shown rite private data and informed of its meaning,The data need not be disclosed to him Ibr six <br /> months t hereaft unless a dispute or action pursuant to tris section is pending or additional data on an individual has barn collected or crated. The <br /> rrsponsMeaud ilyd"Fovidec*cpoftheprivateorpublicdatauponrequcvtbythchdividuatsul#jectofthedaa.Theresponsiblesudicrirymgy <br /> require e the requesting person to pay due actual costs of making,cerdfytng,and compiling The copies. <br /> Mwresponsible m0horkysluatl complyimmediaaely,ifpwaible.with my request mWe pursuant to dw suibdivalon,orwiduofive days oftbe <br /> date of the rcqucst,excluding Saturdays,Sundays and legal holidays,if innmediate oemplianoe is not poesrble. ithe cannot comply with the request <br /> within that time,he shall so inibrm tae Mvidual,and may have an additional five days within which to comply winch the request,excluding Saturdays. <br /> Sundays and legal holidays. <br /> SubdA Proce nwhcndmisnoteacumtoorcomplcte,Anindiv"Imayconhatthesommyorcompleteansofpublieorprivateita <br /> c=waWng b=cX To exercise die right,an individualshall notify in writiogtheresponshblea dbWtydescftgihcaaaue of the disagreement The <br /> responsible authority shall within 30 days oid= (a)correct the data fond to be inaccutais or incomplete and attempt to notify past roapiants of <br /> irraccwata or incomplete dale,including recipients named by due individual;or(b)notify The indivi"got In belio es the data to be eoereae Daum <br /> dispute shall be disclosed only if the individual's statement of dbagressomt is included with do disclosed data. <br /> The detandustim of the mtponsible auaha ty may be appealed pursuant to The provisions of the administrative procedure act relating to <br /> contested cases. <br /> DATA_MtIVACY ADVISQU <br /> In accordance withM.S.13.04,Subd.2,"Rightts ofsubjects of dat a',we would like to informy outhaty=request <br /> for a permit or license from thus City of Orono or any of its departments may require you to furnish certain private or <br /> confidential information. <br /> You are testified that: <br /> 1. The information you finish will be used to determine your qualification for the permit or license <br /> requested. <br /> 2. You may refuse to supply data,but refusal may require diet the City deny the permit or license. <br /> 3. The information may be shared with other local,state or federal agencies to the extent necessary to <br /> process the permit or license. <br /> 4. If your requested permit or license requires Council action to approve,some Wbrmation may become <br /> public. <br /> S. You have certain rights under M.S. 13.04(available upon request)to review private data on yourself <br /> 6. Your full name is required to process this application or permit. <br /> 4 P J Q rro.-t-- �2� ,.�h a bio <br /> First Middle Last <br /> ,q,ddren <br /> if-AJ0.8tr �S7 3�Y� <br /> City State Zip Phone <br /> I understand My rights as stated above. <br /> Signature <br /> 32 <br />