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city <br />OP <br />ORONC^ <br />CITYof ORONO <br />Past Ofric* Boa 66*Cry«Ul Bay, MiaBwata 5S313 • Maaidaal Offlcaa <br />On the /Vorth Shore of lAihe Minnetonka <br />DATA PRIVACY ADVISORY <br />In accordance with M.S. 13.04, Subd. 2, 'Rights of subjects of <br />data”, we would like to inform you that your request for a <br />Special Assessment Deferral from the City of Orono may require <br />you to furnish certain private or confidential information. <br />You are notified that! <br />1. The information you furnish will be used to determine your <br />qualification for the Special Assessment Deferral requested. <br />2. You nay refuse to supply data, but refusal may require that <br />the City deny the Special Assessment Deferral. <br />3. The information nay be shared witht <br />Personnel of any public agency cooperating with the City in <br />administering the special assessment deferrals. <br />City council members: only that information needed to <br />approve the application for grant funds and/or payments to <br />contractors. <br />Federal, state, county, local and contracted private <br />auditors. <br />The contract for deed holder: only to the fact that you are <br />a grant recipient and the amount of the grant. <br />Law enforcement personnel in the caseu of suspected fraud. <br />Those other individuals or agencies to whom you give your <br />express written permission. <br />4. If your requested Special Assessment Deferral rev^uires <br />council action to approve, some information may beco...* <br />public. <br />5. You have certain rights under M.S. 13.04 to review private <br />data on yourself. <br />6. Your full name, and date of birth ate requited to process <br />this application. <br />First Middle Last <br />Address <br />Date of birth <br />Phone <br />I understand my rights as - ated above, <br />X <br />Signature