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. � . Sec.13.04 RIGH'fS OF SUBJECTS OF DATA suba. i. Ty�oe ae�. The rights of individual on whom the data is stored or ro be stored shall be as set forth in this secdon. Subd.2. Information required to be Qiven individual. An individual asked to supp(y private or confidential dara conceming himself shall be�fo�med of: (a)the purpose and intended use of the requested data within the collecting stau agency,polidcal subdivision,or statewide system; (6) wherher he may refuse or is legally roquired to supply the requesud data;(c)any lmown consequence arising from his suPP�Y�B or refusing to suPP�Y private or confidential data;and(d)t6e identiry of other persons or entities authorized by state or federal law to roceive the data. This roquirement shall not apply when an individual is asked to supply investigadve data,pursuant to section 13.82, subdivision S, to a law enforcement officer. 'Ihe commissioner of tevenue mav olace t�nodce�eauited under dvs�bdivision in the individual income taz or�rocertv taz refund instrucdons instead of on those forms. SLbd.3. A�to data by mdividual. Upon request to a responsible authority,an individual shall be iaformed whether 6e is the subject of stored data on individuals,azd w�r it is c�ed as public,private or confidenlial. Upon his turther request,an iadividual who is the subject of stored private or public data on i�ividuals shall be shown the data without any charge ro him and, if he desiies, shall be infocmed of the content and meaning of that data. After an individuai has been shown the private dam and informed of its meaning,the dara need not be disclosed to hun for six months thereafter unless a dispuoe or acdon pursuant w this section is pending or addidonal data on the iadividual has been collecud or cresud. The responsible authoriry shall provide copies of the private or public data upon request by the individual subject of the data. 1'he responsible authoriry may roquire rhe requesting person to pay the actual costs of making,certifying,and compiling the copies. 'Ibe cesponsible aud�rity shall comply immediately, if possible,with any request made pursuant w this subdivision,or within five days of the daoe of the requesc,excluding Sawidays,SLndays and legal holidays,if immediate compiisnce is not possibla If he cannot comply with the request within that time,he shall so infortn the individual,and may have an addidonal five days within whic6 to comply with the request,excluding Saturdays,Sundays and legal holidays. Subd.4. Procedure whw data is not accurate or compkte. An iadividual may contest the accuracy or completeness of public or private data conceming him.celf. To exercise this right,an individual shaU aotify in writing the responsible authority describing the naturo of the disagreement. The nespoosible aud�oriry shall within 30 days either. (a)conect the da�found to be inaccurate or incomplete and attempt to nodfy past recipients of inaccunte or incomple�dara,i�luding ncipients named by the individual;or(b)notify the individual that he believes the data to be correct. Data in dispute shall be disclosed only if the individual's statement of disagreement is included with the disclosed data. 'R�e determinadon of the responsible authoriry may be appealed pu�suant ro du provisioas of the administradve proceduro act rolaang 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 certain private or confidential information. You aze notified that: • 1. The information you fiunish 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 City deny tke permit or license. 3. The information may be shazed 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 nazne is required to process this application or permit. �l�.� 5 (�C��. v�., First Middle Last /� /' - �o � y;�� Address �/� ��j �I� ��y'7 �iZ .S:S 2-�Z� C��Y State Zip Phone I understand as stat � ove. Signature 10