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.�.. Sec.13.04 RIGHTS OF SUBJECTS OF DaT� Subd. 1. Tvpe of data. The rights of individual on whom[he data is stored or to be stored shall be as sec forth in this secrion. Subd.2. Information reqirired to be given indiridual. �.n individual asked to supply privace or confidendal data concerning himself shall be informed of: (a) che purpose and in[ended use of the requested dara within the collecring"stace agency, pofidcai subdivisioo,or statewide rysum; (b)whe[her he may refuse oY is legally required to supply the requested data:(c)any Irnown coasequence arising from his supp(ying or refusing to supply priva[e or conndendal data;and(d)the idenary of ocher persons or endaes auchorized by state or federal law to receive the data. 'Ihis requir:meat s6a11 noc apply when an individual is asked to supply invesrieadve dara, pursuanc to secaon 13.82, subdivision 5, to a law enforcemenc o�cer. The commissioner of re�enue r�av place the norice reauired under this subdivision in the individual income tax or propem nx refund instructions instead of on those forms. Subd. 3. Access to data by indi�-idual. Upon requesc to a responsible auchoriry,an individual shall be informed whether he is che subjecc of scored data on individuals, and whe[her it is classified as public, privace or confidenrial. Upon his further request, an individual who is�he subjecc of scored private or public data on individuals shall be shown the data wichout any cnarge to hirn and,�if he desires, shall be informed of�e concenc and meaning of chac data. Aftzr an individual has been shown the priva[e data and informed of its meaning, the data need not be disclosed[o him for si�c mon�hs chereafrer unless a dispute or acrion pursuan[to this secdon is ptnding or addicional data on the individuai has been collecezd or creaced. The responsible auchoriry shall provide copies of the private or public data upon request by the individual subjecc of rhe data. The responsible authoriry may require the requesring person to pay the acnial cosrs of making, cerdfying, and compiling the copies. The responsible authoriry shall compiy immediately, if possible, wich any request made pursuant to this subdivision,or within five days of the date of the requesc,excluding Saturdays,Sundays and leeal holidays,if immediace compliance is noc possible. If he cannoc comply with�he request within thac dme,he shall so inform che individuai,and may have an addidona!five days wichin which to comply with the request,excluding Saturdays, Sundays and legal holidays. Subd.4. Procedure when data is not accurate or complete. An individual may contest the accuracy or completeness of public or pri�•ate data conceming himself. To exercise chis right,an individual shalt noafy in wriring the responsible authoriry describing�he nacure of the disagreement. The responsibte au�horiry shall within 30 days eicher: (a)correct che data found to be inaccurate or incomple�e and attempc to noafy past rcipiencs of inaccurate or incomplete data, including recipiencs named by[he individual; or(b)notify the individual that he believes[he data to be correct. Data in dispu[e shall be disctosed only if the individuai's sta[emen[of disagreement is included with the disclosed data. The de�erminarion of the responsible auchoriry may be appealzd pursuanc to the provisions of the adminiscrarive procedure act relaang to contesced cases. DAT?� PRIVACY ADVISORY In accordance with M.S. 13.04, Subd.2, "Rights 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 priva[e or confidential information. You are notified that: 1. The information you fumish will be used to determine your qualification for the pemut or license requested. 2. You may refuse to supply data, but refusai may require tha[ the Ciry deny the permit or license. 3, The informa[ion may be shared with ocher local, state or federal agencies [o the excent necessary co process the permit or license. 4. If your requested permit or license requires Council action to approve, some informacion 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. }��« ✓ � �''vl� �I�� �fiddle Lasc First 2 �� �� "��V��S� I-'r�, �� 5 � vC� Address • - � ' ' C��.,,. � � �� Y��-.� `>�V� sI � `1i; 7 ; I , �'�� �iry Stace Zip Phone I understand my rights as stated a,bove. i / , � ��_-�' %�--� Signature