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� Sec.13.04 RIGHTS OF SLTBJECTS OF DATA Subd. 1. Type of data. The righu of individual on whom the data is stored or to be stored shall be as set forth in this secdon. Subd.2. Information required to be given indiridual. An individual asked to supply private or confiden[ial data concerning hunself shall be informed of: (a)the purpose and intended use of the requested data within the collecdng'state agency, poliacal subdivision,or statewide system; (b)whether he may refuse or is 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 idennry of other persons or endries authorized by state or federal law to receive the data. This requirement shall not apply when an individual is asked to suppiy investigative data, pursuant to section 13.82, subdivision 5, to a law enforcement officer. The commissioner of re�enue may place the notice required under this subdivision in the individual income tax or prooertv tax refund instructions instead of on 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 public,priva[e or confidential. Upon his further request,an individual who is the subject of stored private or pubiic data on individuals shall be shown the 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 priva[e data and informed of its meaning, the data need not be disclosed to him for six months thereafter unless a dispute or action pursuant to this section is pending or addirional data on the individual has been collected or created. The responsible auchority shall provide copies of the private or public data upon request by the individual subject of the data. The responsible authority may require the requesring person to pay the actual cosu of making, certifying, and compiling the copies. The responsible authoriry shall comply immediacely, if possible, with any request made pursuant to this subdivision,or within five days of the date of the request,excluding Saturdays,Sundays and legal holidays,if immediate comp(iance is not possible. If he cannot comply with the request within that time,he shall so infornt the individual,and may have an additionai five days within which to comply with the request,excluding Saturdays, Sundays and legal holidays. Subd.4. Procedure when data is not accurate or complete. An individual may contest the accuracy or completeness of public or priva[e data conceming himself. To exercise this right,an individual shall notify in writing the responsible authoriry describing the nature of the disagreement. The responsible authoriry shall within 30 days either: (a)correct the data found to be inaccurate or incomplete and attempt to nocify past recipienu of inaccurate or incomplete data, including recipients named by the individual; or(b)notify the individual that he believes the data to be correct. Data in dispute sha11 be disclosed only if the individual's statement of disagreement is included with the disclosed data. The determinarion of the responsible authoriry may be appealed pursuant to the provisions of the administradve 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 furnish will be used to detemune 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 pemut 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. Your full name is required to process this application or permit. (�'��?�-L a� ��-.� �t� .t c�� 1 � h .c.J c d n-J First �Middle Last Pv �� 3�� - Address _ _-l� �.�N Cl ) �� ./,.�' � J 3 L,� � � -�-� 3 / J ` ��, �State Z�p Phone I understand �rights as stated above. � . . _ ; __ �• � ,�-- � �7L Signature !/