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Sec.13.04 RIGHTS OF SLJBJECTS OF DATA Subd. 1. Type of data. The rights of individual on whom the data is stored or to be stored shall be as set forth in this secaon. Subd.2_ Information reqirired to be g�ioen individual. An individual asked w supplY private or confidendal data conceming hiauelf sha11 be informed of: (a)t�c purpose and in�ended use of the requested dara wichin the collecring'state agency,polidcal subdivision,or statewide sysum: (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 snpply private or confidenaal dara:and(d)che idenary of o[her persons or enrives authorized by state or federal law to receive the data. This requirement shall not apply when an individual is asked to supply in�esvgaave dan, pursuant to secrion 13.82, subdivision 5, to a law enforcement ofFcer. The commissioner of re�enue mav lace the noace re uired under this subdivision in the individual income tax or ro errv tax refund insaucrions instead of on those forms. Subd. 3. Access to data by individual. Upon request to a responsible authority,an individual shall be informed whe[her he is the subject of stored data on individuals,and whether it is classified as public, private or confidendal. Upon his fur[her cequest, an individual who is the subject of stored private or public dara on individuals shall be shown[he data wi[hout any charge to him and, if he Id�ee��e d not be a��o ea�io him[for and meaning of[hat data. After an individual has been shown the priva[e data and informed of i[s meaning, six months thereaf[er unless a dispu[e or acnon pursuant to this secdon is pending or addidonal data on the individual has been collected or creared. The responsible authoriry shall provide copies of the private or public data upon request by the individual subject of the data. The responsible authoriry may require the requesting penon to pay che actual costs of making, cerdfying, and compiling the copies. The responsibte authoriry shall comply immedia[ely, 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 compliance is not possible. If he cannot comply with the reques[ within[hat time,he shall so inform the individual,and may have an addidonal Five days wi[hin which to comply wi[h the request,excluding 3aturdays, Sundays and legal holidays. Subd.4. Procedure wheu data is not accurate or complete. An individual may contest the accuracy or compieteness of public or private data conceming himself. To exercise this right,an individual shail no[ify in wri[ing the responsible authority describing the nature of tha dilec rients o[f The responsible au[horiry shall within 30 days either: (a)correct the data found to be inaccurate or incomplete and attempt to no[ify p P inaccura[e or incomplece data, including recipients named by the individual; or(b)notify the individual that he believes the data to be corcect. Data in dispute shall be disclosed only if the individual's stacement of disagreement is included with the disclosed data. The determination of the responsible authoriry may be appealed pursuant to the provisions of the adminisaadve procedure act relaang co 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 tha[your request for a pernut or license from the Ciry 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 deternune 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 permit or license. 4. If your requested permit or license requires Council action to approve, some information may become public. j, 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. -- __ �1/"IG�-��-� 1.�,� -��"r l�-- �/�='t ��JS f-�'-1«�_. tiiiddle Last First �, ' �lj� /_t�=c=c�S/ �-�-�4 �U � Address .tl�l ��`>��_ >�:, ��' -'�.�-- �� i� �-��—� Phone Stace ZiP City I understand my rights as stated above. �) , ii�%1�-1 � �-�c�� Signawre ` � l,_�