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ORONO ADMINISTRATIVE OFFICES <br /> INFORMATION DISCLOSURE REQUEST <br /> MINNESOTA GOVERNMENT DATA PRACTICES ACT <br /> REQUESTER NOTE: _ Private Data on individuals. After the <br /> ou <br /> A. Request Frequency its <br /> have been supplied the data and informed si.xfmonthsethereafter <br /> data need not be disclosed to ending or additional data -on <br /> unless a dispute or action is p <br /> you has been collected. a actual costs in making, <br /> B. you may be required to pay <br /> copies of information <br /> certif ying and/or compiling <br /> requested. <br /> Date of Request: (� <br /> Requester Name: <br /> Andress: <br /> -10 <br /> W Q,�✓� -� city: (Q i <br /> zip: <br /> Business: <br /> Rome Phone: <br /> Description of Inf orma'tion Requested: 6 <br /> 1 <br /> Requester`s Signature: <br /> BELOW INFORMATION TO BE FILLED IN BY DEPARTMENT ONLY <br /> Handled By: <br /> Department: <br /> Request Type: _In person <br /> Mail Phone <br /> Requested By: _Subj <br /> ec" of Data Not Subject of Data <br /> :Public private <br /> Tnfoffiation Requested is Classified: <br /> _ <br /> _Confidential <br /> Nor.-Public :rotected Non-Public <br /> Request is: Approved <br /> Denied Approved in Part <br /> Remarks/Comments: <br /> Authorized Signature: <br /> x Total Due <br /> Fees:- No. of Pages Rate per Page . <br />