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May 01 07 10:06a Buckshot Exteriors Inc 7636335665 p.2 ttay-01-200T `6R:43am From-CITY OF ORONO +9522494616 T-541 P.002/002 F-180 • Sec.13.04 RIGHTS OF$11.718.TECTS 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 seutiat]. Subs.:. Information required to be given Individual. An individual asked IC/supply private or confidential data concerning himself shall be informed of: (a)the purpose and intended use of the requested data within the collecting state agency,political subdivision,ur statewide system;(b) whether he may refuse or it legally required to supply the requested data;(c)any known consequence arising from his supplying or refusing to supply private or confidential data;and(d)the identity of other persons orentities authorized by state or federal/AV/to receive the data. This requirementshall net apply when an individual is asked to supply investigative data,pursuant to section 13.82,subdivision 5,to a law enforcement oMeer. • The cnntmissioner of rcvenne_mav place the notice regnirgfl ender this subdivision in the individual income tax or property tax refund Instructions instead of en 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 Piddle,private or confdeutial. Upon his further request,an individual who is the subject of stored private or public data on individuals shall be shown th c data without any charge to him and,If he desires,shall be informed of the content and meaning of that data. After an Individual has been shown the private data and informed()fin meaning,the data,need not be disclosed to hint for sit months thereafter unless a dispute or action pursuant to this section is pending or additional data on the Individual has been collected or created. The responsible authority shall provide copies of the privateor public data upon request by the individual subject of the data. The reaponsiblcauthority may require the requesting person to pay the actual costa of making,certifying,and compiling the copies. The responsible authority shall comply irnmediatcly,if possible,with any request made pursuant to this subdivision,or within five days or ihe date of the request,excluding Saturdays,Sundays and legal holidays,If immediate compliance is not possible.If he cannot comply with the request with{r- that time,he shall so inform die Individual,and may hate an additional five days within which to comply with the request,excluding Saturdays,Sundays and legal holidays. Subd.4, l'rocadura when iiLa it net accurate or complete. An individual may contest the accuracy or completeness of public orprivate data concerning himself. To exercise this right,an individual shall notify In writing the responsible authority describing the nature of the disagreement.The responsible authority shall within 3D days either: (a)correct the data found to be inaccurate or Incomplete and attempt to notify past recipients of inaccurate or incomplete data,including recipients named by the individual;or(b)notify the individual Shut he believes the data to be correct. Data to dispute shall he disclosed only if the Individual's statement of disagreement is included with the disclosed data. The determination of the responsible authority may be appealed pursuant to the provisions of the administrative procedure act relating to contested cases. DATA PRIVACY ADVISORY 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 departments may require you to furnish certain private or confidential information. 'You are notified that: 1. The information you harnish 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 Iicense. 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 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. Youri full name is required to process this application or permit. L1�!t E1 cc P I 2 (Y}C61,-14.W A ot) First Middle Last 41 5-03 - moi, _ ,^) - CJD 9 Address 77762-633- EHT r I 3v 5-66r City State Trp Phone I understand my rights as stated above. - `� Signature