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, 09/20/2065 01:49 7634788611 MATRIX INC PAGE 63
<br /> $Cc.1.3.04 RiGHTS O�SURIAt"TS OF DATh
<br /> Snhd 1 Tyr�oFdato. Thc ri�hlc of individuol on whmm tlx����i�nWicJ V�'lu lic 9(0(CO Sb111 bC 05 3C('I'01'lh in[hi5 90CL�0�.
<br /> Suhd,2. Infonnation required lo ho�ivcn individuaL An individnal asked ro surrly pnvate orconfidential dat�concerning himselfsh�ll be
<br /> intormad qf; (a)the purpesc and intended usc af[he requestcd Aata within thc c�lle.r.rin�otare agency,p�litical cubdi�i�ion,o�sUtkcwi�q systcl'u,(1�)
<br /> whcrl�er he mcry rcfusc or is lagully rcquired ro supply�l�c requested dnta;(c)sny known consequcmcc�risin�from his supplying orreFusing t�supply
<br /> privntc or Cppf idenfial data;and(d)lhe idcntiry�ro(htlr per.sc�na oP enlitics¢uthpCi7.Cd by stttteor federal lawtn recelve thc dt�ts,This rcquircmenl shall
<br /> nacapply whan tm individual is askod to supp)y inveatigative data,purvuanS TO 50CLion 13,R2.Subdivision 5,lo:l fnw cnfpicemem�fflCet.
<br /> Thc cmnmissio,ncr of rovenue mav alacc the nolicc ronuircd under this sulidivision in du individual income tnx n�_�ronetty tax refµOCl
<br /> inc: cli�ns instcad of op,thoec Fonns,
<br /> 5ubd.3.xccesStodurAbyindlVidunl. IlprnireqtiCsltoarcgppnSiblcouthnriry,anindividualShnllbcinformedwhcdicrlleisthosub,jcc[af
<br /> s�ored da4ti on individuals.nnd whcclier it is clavsificd as publio,priv3Ce of Can�dcnti9l, Upon hia fu�;he�rcqucst,�n irldividunl who is tho suhjeCl of
<br /> stored privatc nr public datu on i�id'Ividuals shnll b¢shown thc deta wifhout nny charge to him and,if h�dcsircq,sMall bc intormed oFthc contenl und
<br /> mennin�ofthat dutn. Al�.cr nn indi�idunl l,as Uecn sl��w��i1��priva�e d¢m anQ Informod pr Its mcnning,tlte d�fn necd not be diA�logcd t0 him fnr gix
<br /> months theranftcr un��,ss a dispu�c or action pursuant ro this secdon is pending oradditional da�a on the individual has br,�n r.�llected or aroa�cd. The
<br /> responsihle aiuhority shall provide copios nf the privnte or pu�ilic deia upon request by chc individuat sufijec�of the dacn, The responsible autherity
<br /> may rr.quire lhe rrqucsting person r,�pay tha aetuol costs of mukinz,rertitying,anrl rontpiling thc copiee.
<br /> �fhc responsiblo authnri�,v shall camply immediatcly,ifpossible,wit]i any Pequost made pursunnt to rhis subdivision,or Wjthin tive d;i.ys o!'
<br /> die dale of thc reqttesl,exaludinR Safurdvys,Sundays and Icgal holideys,i Fimmcdl�t�campliance IS not posaihlc, ff he cnnn�tcqmplv�dierequesl
<br /> wllhin thattiine,he shull sa info�m thc individuRl.and mny l�ve nn�ddirional five d�ys within wblCh bo comDly wllh lhorcqucsl,excluding SeUlfdnYs,
<br /> Sundaya ar�d lagal holidoy�.
<br /> Su�i�1,4. Procedurowhendamisnotaccurat�arcomplete. Anindividu�IrnAycantestthenccuracyorcompletcne,csofpublicarprival�ednta
<br /> cantcrninghilrlself. TocxerclSelhisriRht,snlndlv�duolshallnntifyinwriringtheres�ponait�laauthoriky�o�ar;bingthcnacureofthc�i�a���.ernent.7hc
<br /> taspon9iblo authotity slixll wilhin 30 da,ys either: (n)corTeCf the doto found ta bc inaccurelte or inenmplete and¢ttcmpt to notify past recipicnca of
<br /> inaccurate or incomplete data,including reeipicn�a named by nc�individu�l;or(b)notify the individual diat hc hclicves the dacs to be coRcc� nat�in
<br /> dispulc shall be disclascd only if fhe individual'S slatemcnt qfdis��gteemcnt is included wi�h the discloEcd dn.t�,
<br /> Thc dcicm,inacion uf�hc�cw��un>iblC authoriry may Ue appcalca pu�suxnt ta thc provisions af[hc s�dministrativc procedarc a�t rclaling to
<br /> cnn[Cyi2d COSCS.
<br /> D A PRIVA ADVIS 1t
<br /> In Acoordanca wi,�h M.S. 13.04,Subd,2,"Rights ol'subjects of data",we would likc to inform vou tl�atyour requcst
<br /> fnr n pormit or iiccnsc frc�m the Cicy uf O��uu ur r�rry uC ics depanmenes may requice you to turni9h ecrtain�rl�ate Or
<br /> confidential information.
<br /> Yuu nrr�wlS�cd that:
<br /> I. The information you furnish will bc used to determine yc�ur qua.li'Iic:ation for the Dcrmit ar license
<br /> requested.
<br /> 2. You may rcfi�sc to supply daca,but refusal may rcquirc that the City deny thc�ermit or licens�.
<br /> 3. The inCormation may be sha.rcd with vther local, St3te�r federal �c:ncira to the pxlcnt necessary to
<br /> process thc permit or license.
<br /> 4, If ypuc requcsted permli or]ieensc requires Council action[o Approvc,sqme information may beeome
<br /> public.
<br /> 5. You havc certain r9ghts undcr M.S. 1.3.04{availabfe upon rcquc.gt)to review private data on yourself.
<br /> G. Your full name is rcquired tq proccss this applicAtion or permit.
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<br /> I undcratA d m rightcS as sta�ted nbavc.
<br /> Sl�npturc
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