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WITY Of vltoNU 612473051009/24/96 1.4:00 ( l :03/03 N0:522 • Sao.13.o4•RIGHTS OF SUBJECTS OF DATA Subd, 1. Type of dela. Thu rights of Individual est whom the data Is-stored or to be stored shall be as at ford!In this seeder. Subd.2. iniorrnatian required to be gists htdly dtml. An Individual asked to supply privets or confidential data concerning hlttuelrtMll be Informed on (a)the puuporo and intended use of the reques>ad data within the colletuing;tate agency,political subdivision,nr sitoolde system: (b)whether he may refute or Is legally required to supply the requested dans(el any known conte ueaa arising hem his supplying or refusing to supply private er eomfldential dug and(d)the identity of oilier persons or enddes authorised by seam or federal awns receive die data. 'This requirement shell oat apply when an individual Is asked to supply lavestillative daa,puauant to section 13:82,subdivision S.to a law enforcement offlar. . it; ,ata. 7.,a , •.V-!:C t'V • '1e t1 Ce L'1 u' i:. ,' . e' V I!i ., !,.- t:v,' . ..err ' • e 't,,,,,s 0. •l•Li! "' ygptrvcdont Igraui 9(on One forms. • . SW,3. Aceaaa to data by Individual. Upon request to a reapanaible authority.an individual shall be Informed whether he Is the subject of tooted data on individuals.and Whither it is ciaaalfied as public.'Mime or cont d tidal. Upon his furter tautest,an individual who is the subject of stored private or public des on lodividusis shall be shown the dam without any chaipe to bite aril,If he desires.shall be informed of the content and meaning of'Medan. After an individual las bean shown the private due and thronged of Ila meaning.the data need web.disrJosed stint far six lesonths(hereauiar union a dispute or action pursuant to dile seeded is pending ler additional data on the individual hat been collected or created. The Ovoidal*atathgrigl shall provide copies of the private or public data upon request by the individual abject of the data. The responsible authority may require du raquaatins person to pay tiro actual costs of making.certifying,and compiling dee copies. . The responsible authority.shall comply immediately,if possible.with any request nude pursuant to this subdivision,or within Ave days of the date of the request.eircluding aaarrdays,Sundays and legal holidays,Ir 6nteedlara compliance Is not possible. Ulla cantos comply with the request . • within that time,he shall sa inform the individual,and may have an additional five days within which to comply with the tequeet.exoludhig Sawrdays. Sadao and legal holidays. Subd.4. Procedure when dote is one accurate or enmplese. An Individual may contest the accuracy or completeness of public or private . data soneoreleg tilnueit To exercise this tight.an iedWlduel shall nod[y in tvtWng the responsible authority describing due nature of the diragt+eentena The mspeasIbie authority shall within 30 days wither. (a)cornet the data found to be iaacaieate or irrcoonpleta and atnmapt to notify put recipients of• tr acoutate or Incomplete n te data,Including recipients named by the individual;or(b)notify.the htdlvklual that he believes the data to be correct. Data • In dispute shall bedisclosed only if the individual's statement of disagreement Is included with the disclosed dui. . • The deartnination or the responsible authority may be appealed pursuant to the prvvisinna of the administndve procedure act relating to concerted eases. • ' - ' • PATA PRIVACY ADVISORY • . . ' In accordance with M.S. 13.0d.Subd.2, "Rights of subjects of data'. we would like to inform you that yourregteat 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. S You are'notified that: • 1. The Information you furnish will be used'to determine your qualification for the permit oriicense requested. 2. • You may refuse to supply data, butrefusal 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. . If your requested permit or license requires Connell 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. • .i a tis. . ' `t`Q . . • ,+ • _ ' r Mudd Last - • ,o .50T` . S s,;_ # _ 11 • ' ', ' l' • •rnry 4 . 9.5_ •3y5- _' - , Clty Sona zip • ]shone • • 1•underatand• my rights as stared above. . ' CA..A—'O....C?:,4_________ .• . Signature . • £/£ ' d £ lL£ ' °N WVLO : II HOZ ' ZZ ' uer