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ORONO AD=ISTRATSYE OFFICES <br /> INFORMATION DISCLOSURE REQUEST <br /> MINNESOTA GOVIMIU6ENT DATA PRACTICES ACT <br /> REQUESTER NOTE: ls • <br /> A. Request Frequency - Private Data on individua . After you <br /> have been supplied the data and informed of its meaning, the <br /> data need not be disclosed to you for six months thereafter <br /> unless .a dispute or action is pending or additional data -on <br /> you .has been collected. <br /> B. you may be required to pay actual costs in making, <br /> certifying and/or compiling the copies of information <br /> requested. <br /> Date of Request: �� <br /> Requester Name: <br /> City: <br /> Address: <br /> zip: <br /> Business: `� ��' <br /> Home Phone: <br /> • /,� <br /> Description of Information Requested: <br /> "V1 <br /> Requesters Signature: <br /> BELOW INFORMATION TO BE FILLED IN BY DEPARTMENT ONLY <br /> Handled By: <br /> Department: <br /> Request Type: In person Mail Phone <br /> Requested By: _Subject of Data <br /> Not Subject of Data <br /> Information Requested is Classified: Public _Private <br /> _Confidential Non-Public Protected Non-Public <br /> Request is: Aooroved <br /> Denied Approved in Part <br /> Remarks/Camments: <br /> Authorized Signature: <br /> Fees:• x Total Due ,. <br /> No. of Pages Rate per Page <br />