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a Sec.13.04 RIGHTS OF SUB.TECTS OF Da.T?, Subd. I. Type of data. The righrs of individual on whom the data is stored or to be scored s6all be as set for[h in this secdon. Subd.2. Information required to be�ven individual. ?.n individual asked to supply priva[e or confideaaal data conceming himself shall be informed of: (a) the purpose and inceoded use of the requested da[a wichin the collecting'stace ageocy, polidcal subdivision,or stacewide system; (b)whe�her he may refuse or is legally required to supply the requested data;(c)any lmown consequence arising from his supplying or refusing to supply privace or confidendal data;and(d)[he idenary of ocher persons or enrides auchorized by state or federal law to receive the data. This requirement shall no�appty when an individual is asked �o supply invesagaave dara, pursuanc to secdon 13.82, subdivision 5, to a law enforcemeo[o�cer. "Ihe commissioner of revenue mav place the notice required under this subdivision in the individual income taz or prooercv taz refund instcucaons instead of on[hose forms. Subd. 3. Access to data by individual. Upon request to a responsible authoriry,an individual shall be informed wherher he is the subject of stored data on individuals, and whed�er i[is classified as public, privace or confidenoal. Upon his funher request,an individual who is the subjecc of stored private or public data on individuals shall be shown the data wichout any charge to him and, if he desires, shall be iniormed of the content and meaning of that data. After an individual has been shown[hz privace dara and informed of its meaaing, the data need not be disclosed to him for six monrhs chereafter unless a dispuce or acdon pursuant to this section is pending or addiaonal data on rhe individual has been collected or created. The responsible authoriry shall provide copies of the privace or public data upon request by the individual subjecc of[he data. The responsible authoriry may require the requesang person to pay the actual costs of making, cemfying, and compiling the copies. The responsible authoriry shall comply immediately, if possible, with any request made pursuanc to this subdivision, or wichin five days of rhe date of the request,excluding Sacurdays,Sundays and legal holidays,if immediace compliance is not possible. If he cannoc comply with the requesc within that time,he shall so inform the individual,and may have an addidonal five days wi[hin which to comply wich the request,excluding Saturdays, Sundays and legat holidays. Subd.4. Procedure when data is not accurate or complete. An individual may contest the accuracy or compleceness of public or private data concerning himself. To exercise[his right,an individual shall norify in wriring che responsible authoriry describing the nature of the disagreement. The responsibte authoriry shall wichin 30 days either: (a)correcc the data found to be inaccurace or incomplete and attempt to norify past recipients of inaccurate or incomplete data, including recipients named by che individual; or(b)nodfy the individual [hat he believes the data to be correct. Data in dispute shali be discfosed only if the individual's statement of disagreement is included with the disclosed data. Th�determination of the responsible auchoriry may be appealed pursuant to the provisions of the administradve procedure act relaaag to 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 that your request for a permit or license from the City of Orono or any of its departments may require you to fumish cenain 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 Ciry 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. 5. 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 [his application or permit. ,J� �� E�e_ �_�i�e�-f< First Middle Last 3 �? 3� I��c�� Lc e � Address (.��ey�.�� ?7�� S:S 3<�i y?1 -�1//3 � Ci �' State Zip Phone ry I understand my rights as stated abov,�. � ��i��u� "�--- . Signature ��.�