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ORONO AD=ISTR.ATIVE OFFICES <br /> INFORMATION DISCLODSSUREPR REQUEST <br /> ACT <br /> �NNESOTA Ga <br /> REQUESTER NOTE: <br /> A. Request Frequency - Private Data on individuals. After the <br /> have been suppli.eQith disclosed to youdata andf foresixf monthsitse aninghereafter <br /> data need not be - , ending or additional data -on <br /> unless 'a dispute or ac..zon is 'p <br /> you .has been collected. <br /> B. You may be required to pay actual costs in making, <br /> certifying and/For compiling the copies of information <br /> requested. <br /> 2D�C <br /> Date of Request: nit J �_/ 5- <br /> Requester <br /> Requester Name= 0 <br /> Address: - ` <br /> 54- � N City: 1 0 <br /> zip: � s - <br /> �� Business: <br /> Rome Phone: /1 <br /> of Information Requested:. /� S <br /> Description <br /> -ems - v <br /> Requester'. s Sign <br /> BELOW INFORMATION TO BE FILLED IN BY DEPARTMENT ONLY <br /> &-Z, Handled By: <br /> Department: <br /> Mail Phone <br /> Request Type: f\In Person . — — <br /> Requested By: Subject of Data -Not Subject of Data <br /> Public Private <br /> Tufoimation Requested is Classified: <br /> _� — <br /> Protected Non-Public <br /> Confidential Non-public <br /> Approved in Part <br /> _Q�Approved Denied -- - <br /> Request is: — <br /> Remarks/Cam=ents: <br /> Authorized Signature: <br /> x l Due <br /> Fees: Tota _ <br /> No. of Pages Rate per Page <br />