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OR02i0 ADMIN25�RATIVE OFFS�ES - <br /> INFORMATION DIS�'DATA PR CTIC�S ACT <br /> • � �NESOTA Ga , <br /> • gEQl7ES�E�Z N07'E: � • T"' '" ou <br /> A, gecruest Frequenc� - Private Data on individuals. F`e- th� <br /> have been supplied the data and uf fQ eSZXfmon�seth nezfter � <br /> data ize�d not be disclosed to 1'ending vr additional data 'on <br /> � .unless .�a dispute or ac..zon is -p � <br /> you .has been col.lected. <br /> You �ay be reauirec to pay��zC�u�� .�os�s in �akinq, <br /> B. zhe copies o� inLO=�zt1Or <br /> certifying an3%or com�iling <br /> requested. � � �r / ' <br /> / � , <br /> Date of Request: �P <br /> r ' <br /> gequester Names . <br /> U - — City: <br /> Ac3dsess: <br /> � zip: � � <br /> H�e Phone: <br /> %S- o'Z � L�� (p O lo SBusiness: <br /> Descripti.oa of =�°�a��n Re�este3:. <br /> Retraester'. s Si,gnature: <br /> BFyOW =NgORbiATION TO BE FIT.,L <br /> IN BY DEPAR�'M�'�T OhZ�Y <br /> sanalea sys <br /> D ep ar�ent_ <br /> Mail Phone <br /> gequ.est Type= —xn Pe'-"son . — — <br /> Subjec� o= Data <br /> Not Su:o je�� oi Data <br /> geques�ed Sy= — <br /> �ublic _P=iv�te <br /> Tnfoz�a.tr.on Requested is Classified= — <br /> Na�_�ubZi� _-rotected Non-Public <br /> Con=idential � . _� Y�� <br /> Denied � Anproved _- - - <br /> gecruest is: Aoproved — <br /> Re�arks/Co�ments= <br /> � • � � � ��' <br /> Anthori-z ed S ignature: �/ " . <br /> �` � _ $ <br /> x Total Due __ <br /> Fees:• eS Rate per Page <br /> No. of Pag . <br />