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'rFel�•:. Sec.13.04 RIGHTS OF SUBJECTS OF DATA Subd. 1. Type of data. The righu of individual on whom the data is stored or to be stored shall be as set forth in this secdon. Subd.2. Information reqirired to be given individual. An individual asked to suppiy private or confidential data conceming himself shall be informed of: (a)the purpose and incended use of the requested dara within the collecting'state agency,polidcal subdivision,or statewide system; (b)whether he may refuse ot is legaliy required to supply che requested data:(c)any laiown consequence arising from his supplying or refusing to supply private or confidendal data;and(d)the idenriry of o[her persons or enades authorized by state or federal law to receive the data. This requirement shall not apply when an individual is asked to supply investigadve dara, pursuant to secrion 13.82, subdivision 5, to a law enforcement officer. The commissioner of re�enue mav place the notice required under this subdivision in the individual income tax or propertV tax refund instructions inscead of on those forms. Subd. 3. Access to data b�individual. Upon request to a responsible authoriry,an individual shall be informed whether he is the subject of stored data on individuals,and whe[her it is classified as public, private or confidenrial. Upon his fucther 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 chat data. After an individual has been shown che private data and informed of its meaning,the data need not be disclosed to him for six months thereafrer unless a dispute or acrion pursuan[to this secdon is pending or addidonal data on the individual has been collected or created. The responsible authoriry shall provide copies of the private or public data upon request by the individual subject of the data. The responsible authoriry may require the requesdng person to pay the actuai costs of making, certifying, 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 immediace compliance is not possible. If he cannot comply with the request within that time,he shall so inform the individuai,and may have an additional five days within 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 private data conceming himself. To exercise this right,an individua(shall norify in writing the responsible authoriry describing the nature of the disagreement. The responsible authoriry shall within 30 days either. (a)correct the data found to be inaccurate or incomplete and attempt to norify past recipienu of inaccurate or incomplete data, including recipients named by the individual; or(b)noafy the individual that he believes the data to be correct. Data in dispute shall be disclosed only if che individual's statement of disagreement is included with the disclosed data. The de[erminarion of the responsible authoriry may be appealed pursuant to the provisions of the administradve procedure act reladng 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 are notified that: 1. The information you furnish will be used to determine your qualification for the pemut or license requested. 2. You may refuse to supply data, but refusal may require that the City 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 pernut 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. (. Your full name is required to process this application or permit. �� k� �u��.��.� ��. �:�,� ��.�� c�� _ First Middle Last � o �o x �-�-{� � — Address rtA � �� / _��Q � �� l City Sta[e Zip Phone I understand my rights as stated above. } � `� Signature