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City of Orono 01 <br /> Information Disclosure Requests <br /> Minnesota Government Data Practices Act \-;t <br /> I <br /> • <br /> Completed by Requester aP�l/1>°/O/,r7 (Qt c yi y �� 14/f-O rru v 5 0 J r n <br /> Requester Name(Last First,MI): (\ Date of Request: ///1 g <br /> C,[l.ro I 5CLt.u- e_ P O <br /> Email: � � Request Type: 0 In-Person 0 Mail <br /> 00—r0(.p�tl� itzfi l ee p//) . LA 3 Email ❑ Fax <br /> Street AddrBss: Phone Number: <br /> /aa000 6o0e/l✓Yl e 7 Cert-1-6r lv/ -3 / - 1poFO <br /> City,State,Zip Code: Signature: <br /> Minn 01/5, /1/(l ,5,52--/F7 <br /> Note: MS§ 13.0&subd. 12,persons may not be required to identify themselves,state a reason for,or justify a request to gain <br /> access to public government data.A person may be asked to provide certain identifying or clarifying information for the sole <br /> purpose of facilitating access to the data. <br /> Description of the Information Requested: <br /> I have read the information on this form and understand the city may charge fees to provide the information I have requested. <br /> Signature <br /> Completed by Department—Office Use Only <br /> Department: Processed By: <br /> AJO <br /> Method of Response: 0 In-Person 0 Phone 0 Mail Information Classification: <br /> Email 0 Fax Public 0 Private 0 Non-Public <br /> ❑ Confidential 0 Protected Non-Public <br /> Action: Approved Requested by: <br /> O Approved in Part(Explain below) 0 Subject of Data <br /> O Denied(Explain below) ,Not Subject of Data <br /> Remarks or basis for denial,include statute section: Identity Verified for Private Information: <br /> ❑ Identification(DL,State ID,etc.) <br /> O ompare Signature on File <br /> Personal Knowledge <br /> O Other <br /> Note: MS§ 13.03,subd.3,authorizes the city to charge fees to recover costs to provide copies of data,including costs <br /> associated with searching,compiling,copying,mailing or otherwise transmitting data. Prepayment is required prior to receiving <br /> copies of data. There is no charge for inspection of data or for separating not public data from public data. <br /> Copy charges: Method of Payment: <br /> O (8''A x 11/14") X 0.25 0 Cash <br /> (#of pages) 0 Check <br /> O (11x17") X 1.00 0 Visa <br /> (#of pages) 0 Master Card <br /> O Employee Time($ /hr) X hrs <br /> (only charge if over 100 pages) <br /> 0 Other Charges(attach explanation) Received by: <br /> Total Amount Due: $ Date: <br /> This request will be reviewed by staff and the requester will be provided an estimate of charges prior to copying. <br /> If mailed,return form to: City of Orono,P.O.Box 66,Crystal Bay,MN 55323 <br /> City of Orono, 2750 Kelley Parkway, Orono,MN 55356 <br /> Phone: 952-249-4600 •Fax: 952-249-4616 • Website: www.ci.orono.mn.us <br />