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` ' � . � Sec.13.04 RIGHTS OF SUBJECTS 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 section. Subd.2. Information required to be given individual. An individual asked to supply private or confidendal dara concerning himself shall be informed of: (a)the purpose and intended use of the requested data within the collecting'state agency,polidcal subdivision,or statewide system; (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 supply private or confidendal data;and(d)the idendry of other persons or entides authorized by state or federai law to receive the data. This requirement shall not apply when an individual is asked to supply investigadve data, pursuant to section 13.82, subdivision 5, to a law enforcement officer. The commissioner of revenue maV place the notice required under this subdivisio❑ in [he individual income tax or propertv tax refund instrucrions instead of on those forms. Subd. 3. Access to data by individual. Upon request to a responsible 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 confidendal. Upon his further request, an individual who is the subject of stored private or public data on individuals shall be shown the data without any charge to him and, if he desires, shall be informed of the content and meaning of that data. After an individual has been shown the private data and informed of its meaning,the data need not be disclosed to him for six months thereafrer unless a dispute or acrion pursuant to this secdon is pending or additional data on the individual has been collected or created. The responsible authority shall provide copies of the private or public data upon request by the individual subject of the data. The responsible authority may require the requesting person to pay the actual costs of making, cerdfying, and compiling the copies. The responsible authoriry shall comply immediately, 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 that rime,he shall so inform the individual,and may have an additional five days within which to comply with the request,excluding Saturdays, Sundays and legal hulidays. Subd.4. Procedure when data is not accurate or complete. An individual may contest the accuracy or completeness of public or private data concerning himself. To exercise this right,an individual shall notify in writing the responsible authoriry describing the nature of the disagreement. The responsible authority shall within 30 days either. (a)correct the data found to be inaccurate or incomplete and attempt to notify past recipienzs of inaccura[e or incomplete data, including recipients named by the 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 disa¢reement is included with the disclosed data. The determination of the responsible authoriry may be appealed pursuant to the provisions of the administrative procedure act relating 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 yon that your request for a permit or license from the City of Orono or any of its departments may require you to furnish certain pri��ate or confidential information. You are notified that: 1. The information you furnish will be used to determine your qualification for the pernut or license requested. 2. You may refuse to suppiy data, but refusal may require that the City deny the pernut 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 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 this application or permit. -� ��( J� (!'`"�,��J �,1 C'(��L!1`r� �./J - ��i��C� � , / Mid e Last First , / f `� j -� ` ( /' Ad refss , ' �"l � •� / � �G � � S",--��/�1 L_'L'`J Ciry / State Zip t Phone `�� � 33 I understand my rights as stated above. , a ,,., � 9 J/ L � i' � >'' f !�r- ` / `./� � Signature