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_f <br /> :, <br /> Sec.13.04 RIGHTS OF SUFi.TECTS OF DAT� <br /> Subd. 1. Type ot'data. Tha riohcs of individual on whom the data is scored or to be scor•d shalI be as sec forch in this secdon. <br /> Subd.2. Information reqirired to be given indir-idual. An iadividual asked to supply privace or confideaaal dara concemiag himseif shall <br /> bz informed of: (a) [fie purpose aud inc:nded use of the requesc�dara wichin the eollecdng itat�agency, polidcal subdivisioo,or sntewide rynem; <br /> (b)whe�her he may r.'use oi is legally requird to supply the r.quu�ed daca;(c)aay lrnown eoasequcnce arising from his supplying or refusing to supply <br /> private oreonndenriai dara;and(d)th:idendry of a�herptrsoas or enaacs auchoriz:d by sc�te or federal law to teceive tha data. This requiremeat shall <br /> not appty wh�n an individual is asked to suppiy invesri�aave data,pursuanc to secaon 13.82,subdivision 5, to a law enforcemen�ofricer. - <br /> Tht commissioner of revenue mav olace tha nodce r_�uir_d und�r u4is subdivision in the individual income taz or orooem taz refurd <br /> inscrucdor.s inscead of on chose forms. <br /> Subd. 3. Access to data by indiridual. lipon request co a responsible au�horiry,an individual shall be informed whe�her he is the subject <br /> of scnrd dat�on individuals,and whe�her ic is elassified as pubtic, privace or conFdendal. Upon his further reques�,an individual who is the subjec� <br /> of s�ored privace or public daca on individuals shall ba shown the dat�wichout any charge to him and;if he desires, shall be informed of the concenc <br /> and meaning of�hat data. Aher an individu�l has been shown the privacz data and informed of its meaaing, the dara need not be disclosed to him for <br /> six moncns ct:ercatur uriless a dispute or acaon pucsuane co this secaon is pending or addidoaal data on the individua!has been cotlecced or creared. <br /> Tht rsponsibta authoriry shall pcovide copies of the privaee orpublic data upon tequest by the individu�I subjece of[hz data. Tne responsible aucfioriry <br /> may require the requesdng person to pay the accua!costs of rnaking,cerafying,and compiling[he copies. <br /> The responsible auchoriry shall compiy immediately,if possibte, wi�h any request made pursuant to this subdivision,or wichin five days of <br /> the da[e of[he request,ezciuding Sacurdays,Sundays and legal holidays,if immzdiate compliance is not possibte. If he cannot comply with the requesc <br /> wichin that time,he shal!so inform the individual,and may have an addirionai five days within which to comply with the request,exciuding Saturdays, <br /> Sundays and legal holidays. <br /> Subd.4. Procedure when data is not accurate or comptete. An individual may contest the accuncy or completeness of pubiic or pri�ate <br /> data concerning hir.iselF. To exercise chis ri¢ht,an individual shall noa"ry in wriang che responsible authoriry describing the nacure of the disagreemenG <br /> The responsibte authoriry shail within 30 days eichec: (a)correcc[he data found to be inaccucate or incomplete ar.d attempt to nodfy past recipiencs of <br /> inaccunte or incomplece data, including recipienes narr,ed by ebe individual;or(b)noafy the individual that he believes che data to be cocrecc Data <br /> in dispute sfiali be disclosed only if the individual's sc3temenc of disagreement is inctuded with[he disclosed data. <br /> The decerminadon of the responsible au�horiry may be appealed pursuant to [he provisions of thz adminisaarive procedure act re(aang to <br /> cont_sted eases. <br /> DATA PRiVACY ADVISORY <br /> In accordance with M.S. 13.04, Subd.2, "Rights of subjects of data", we would like to inform you that your request <br /> for a permit or license from the Ciry of Orono or any of its deparcments may require you to fumish certain private or <br /> confidencial information. <br /> You are notified that: • <br /> i. The information you furnish will be used to determine your qualification for the permit or license requested. <br /> 2. You may refuse to supply data, buc refusal may require that the Ciry deny the permit or license. <br /> 3. The information may be shared with other local, sta[e or federal a�encies to the eztent necessary to process <br /> ' the permit or license. <br /> 4. If your requested permit or license requcres Council action to approve, some informa[ion may become <br /> public. <br /> 5. You have certain ri�hts under M.S. 13.04 (available upon request) to review private data on yourself. <br /> 6. Your full name is required to process this application or permic. <br /> ��4� � j�'� '� I'� <br /> Firsc Middle Lasc <br /> �� � �� � �`l u����� )�� 2/�`� <br /> Address�r� �� Y�� ��S� t�� Z� � I�_�c� --�n � ���. <br /> b' ' <br /> Ciry Srate Zip Phoae <br /> (- <br /> I u erst my ri�hts sta[e ove <br /> �\ <br /> Signature <br />