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ORONO ADMINISTRATIVE OFFICES <br /> INFORMATION DISCLOSURE REQUEST <br /> MINNESOTA GOVERNMENT DATA PRACTICES ACT <br /> REQUESTER NOTE: <br /> A. Request Frequency - Private Data on individuals. 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 /> iii/ C Icy <br /> Date of Request: <br /> Requester Name: 5 <br /> 0.-tt 6tuarVi <br /> Address: <br /> ( t4-r v ! ttti L u_ kik 't City: CV-0 C 1\ 0 <br /> Zip: , <br /> __� Business: t-U r�1 e 4 G- ( `F <br /> Home Phone: ti -7 -3 ` / �t �� <br /> Description of Information Requested: <br /> 4-Is-Lis lwu l �c,� <br /> Ile,- ., �� Rd <br /> Requester' s Signature: <br /> BELOW INFORMATION TO BE FILLED IN BY DEPARTMENT ONLY <br /> Department: <br /> Handled By: <br /> Request Type: In person Mail Phone <br /> Requested By: Subject of Data Not Subject of Data <br /> eqa <br /> Information Requested is Classified: <br /> Public Private <br /> Confidential Non-Public Protected Non-Public <br /> Request is: Approved Denied Approved in Part <br /> Remarks/Comments: <br /> Authorized Signature: <br /> Fees: x $Total Due <br /> No. of Pages Rate per Page <br />