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Sec.13.04 RIGHTSOFSUBJECTSOFDATA Subdivision 1. Type oJdata. The rights ojrndividual on whom the data rs slored or ta be stored shall be as set forth in this section. Subd.2. Information requi�ed to be glven individuaL An individua!asked to supply private or confidentral dara concerning himself '� sha11 be informed of.• (a)the purpose and intended tese of the requesfed data within the collecling slate agency,politica!subdivisron,or stateivide L system;(6)whether he may refuse or is fega!!y required to supply the requested data;(c)any knotivn consequence arisrng from his supplying or refusing to supplyprivate or confidenlial data;and(d)the idenfrty ofolher persons or entities authorized byslate orfederallmv to receive the data. This requirement shall not apply when an rndivrdua!is asked to supply imestigative data,pursuant to section 13.81, subdivision 5, to a!mv enjorcement o�cer. The commissioner ofrevenue mav Dlace!he notrce required under this subdivision in the individua!rncome tax or prooerty tax refund instruclions�nstead o{on those forms. Subd.3. Access to data by individual. Upon reguest to a responsible aulhority,an indivrd:�al shal!be informed whether he is�he subject ojstored data on individuals, and whether it is classrfied as public,prrvate or confidential. Upon his further request,an rndividual who is the siebject ofstored private or publie data on individuals shall be shoivn the data ivithout any charge to hrm and,if he desrres,shall be rnformed oJ � the content and meaning of that data. Afler an indrvidual has been shotivn the private data and rnjormed of its meaning, the data need not be disclosed to him for six months thereafter unless a dispute or action pursuant to this section is pending or additiona!data on the individual has been co!lected or created. The responsible authority shall provide copies oJthe private or public data:rpon req:�est by the individual subject of 1he data. The responsible authoriry may require the requesting person to pay the aclual cosrs ojmaking,cert�ing,and comprling the copres. The responsible authoriry shall comply immediately,:fpossible,tivith any reqt�esr made pursuant to lhrs subdivision,or within five days of the date oJthe request,excluding Saturdays,Sundays and legal holidays,ijimmediate complrance is not possible. Ijhe cannot comply with the request lvrthin that time,he shall so inform the indivJdual,and may have an additional frve days ivrthin tivhich 10 comply with the request,excluding Sat:�rdays,Sundays and legal holidays. Subd.4. Procedure when data is not accu�ate or complete.An individua(may contest the accuracy or completeness ojpublic orprivate data concerning himself. To exercise this right, an individ:�al shal!nolify in writing the responsible authority describing the nature of!he disagreement. The responsible autharity shall wilhin 30 days either: (a)correct the datajo:rnd to be inaccurate or incomplete and attemp!to not� past recrpients ojinaccurate or incomplete data,including recipients named by the individual;or(b)not�the individual that he believes the data to be correct. Data in drspute shal!be disclosed only iflhe individua!'s statement ofdisagreement is inc[uded with the disclosed data. The determrnation oJthe responsible authority may be appealedpursuant to the provrsions ofthe adminrstrative procedure act relating to conlested cases. DATA PRIVACYAD[�ISORY In accordance wilh M.S.13.04,Subd.2,'Rights ofsubjects ofdata",ive tivould like to informyou thatyourrequestforapermit orlicense from the City of Orono or any of its departments may regerire you to furnish certain prlvate or confrdential information. You are notified that. 1. The information yot�jurnish tivi!!be trsed to detennrne your qualifrcation for the permit or license reguested. 2. Yo�i may rejuse to supply data,but refusa!may require that!he Ciry deny the permit or license. 3. The injormation may be shared with other local,state or federal agencies to the extent necessary fo process the permit or license. 4. Ijyour requested permit or Ircense requires Council action to approve,some injormation may become public. 5. You have certain rights under M.S. 13.04(see follolving page)to revietiv private data on yourself. 6. Your ful!name is required to process this applicalion or permit. PLEASE PR1NT __:�c��I i�i C_`i � i � c� f%O�-L_- Ftrst Mrddle Last / , - / Z C.t.� ��-"7,, `%'i �d ; 1,r Address � __� �-- ;%�C:-��, �, � r�<__ i�>`� � �-_�,� �j�`-z -� ' ��.�i� 9"/ ,ry � - sia�e ' Z�P Phone I understand righls as st7P�f ove. � � /� �� i i ;,G'-/L".zh_, Signa�fYre� /0