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• Sea13.04 RIGHTS OF SUBJECTS OF DaTA Subd. 1. Type of data. The rights of individual on whom che data is stored or to be stored shall be as set forth in this secdon. Subd.2. Information required to be given individual. An individual asked to suppty private or confidential data concerning himself shall be informed of: (a)the purpose and iatended use of che requested dara within[he collecang"state agency, poliacal subdivision,or sratewide system; (b)whether he may refuse oY is legally required to supply rhe requested data;(c)any known consequence arising fmm his supplying or refusing to supply priva�e or confidential data;and(d)the iden�icy of ocher persons or enndes authorized by state or federal law to receive the data. This requirement shall not apply when an individuat is asked to suppty invesrieadve dara, pursuant ro secdon 13.82, subdivision 5, to a law enforcement ofFicer. The commissioner of re�•enue mav place the ❑oace reouired under this subdivision in the individual income tax or propertv tax refund instructions instead of on those forms. � Subd. 3. Access to data by indi��dual. Upon requesc to a responsibfe authoriry,an individual shall be informed whether he is the subject of stored data on individuals, and whether it is classified as public, private or confidenrial. Upon his funher request,an individual who is the subject of scored private or public data on individuals shall be shown che data wiehout any charge to hun and, if he desires, shall be informed of the content and meaning of[hat data. Afrzr an individual has been shown[he private data and informed of its meaning, the data need not be disclosed to him for six mon[hs thereafter unless a dispute or acrion pursuant to [his secaon is pending or additional data on the individuai has been collected or created. The responsible aurhoriry shall provide copies of the privace or public data upon request by the individual subject of che data. The responsible authoriry may require [he requesting person to pay the actual costs of making, cenifying, and compiling the copies. The responsible authoriry shall comply immediately, if possible, with any request made pursuant to this subdivision,o�within five days of the date of the request,exduding Saturdays,Sundays and legal holidays,if immediate compliance is not possible. If he cannot comply with the request within�hat time,he shall so inform the individual,and may have an additional five days within which to comply with the request,excluding Saturdays, 5undays and legal holidays. Subd.4. Procedure when data is not accurate or complete. An individual may contest the accuncy or completeness of public or private dara conceming himself. To exercise chis rieht,an individual shall nodfy in writing the responsible authori[y describing rhe nature of the disagreement. The responsible authoriry shall within 30 days either. (a)correct the data found ro be inaccurate or incomplete and attempt to nodfy past recipienu of inaccurate or incomplete data, induding recipiencs named by [he individual; or(b)notify the individual that he believes the data to be correct. Data in dispute shali be disclosed only if the individual's statement of disagreemen[is included with the disclosed data. Tt�e determination of the rtsponsible authoriry may be appealed pursuant to the provisions of the administra[ive procedure act reladng to contested cases. DAT� PRIVACY ADVISORY In accordance with M.S. 13.04, Subd.2, "Ri�hts of subjects of data", we would like to inform you that your reauest 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 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 pemut or license. 3, The information may be shared with other local, state or federal agencies to the extent necessary to process the pernut or license. 4. If your requested pernut or license requires Council action to approve, some information may become public. �. You have certain rights under M.S. 13.04 (available upon request) to review private data on yourself. (. Your full name is required to process this application or permit. s�� ,�'-� �l z-�-, ��,--i�� -, First c �! �� dlz Las[ Lj / / ! /T�/��`�'/ `� � /�v� — Address �,�r�� l��7 �.��i �5 J" ,� 3 � �C=�`.S� � �'�ll 3 / Ci� State Zip Phone I understand my ri?hts as stated above. r' � —�_� l_..------_--- _. Signature