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City of Orono <br /> Information Disclosure Request <br /> Minnesota Government Data Practices Act <br /> Completed by Requester N44'i/l e/0i,7 /i/7b r V 15 o rr'� <br /> Requester Nam(ast First,MI): Date/of Request: // j g <br /> ( -ô1 c.1t.wH- Pa-ttr /5./..it , <br /> J <br /> Email: J� " � Request Type: ❑ In-Person ❑ Mail <br /> CO00--r0( c1L /"(k{9tlep%n • u 5 Email ❑ Fax <br /> Street Addrbss: Phone Number: <br /> /ao2000 60k)erri►M2rt C�+-Gr lvla-3L/ 400F0 <br /> City,State,Zip Code: / Signature: <br /> NL� ✓lne& o/15,i /u S Z/$'7 <br /> Note: MS§ 13.0&subd. 12,persons may not be required to identify themselves,state a reason for,or justify a request to gain <br /> access to public government data.A person may be asked to provide certain identifying or clarifying information for the sole <br /> purpose of facilitating access to the data. <br /> Description of the Information Requested: <br /> I have read the information on this form and understand the city may charge fees to provide the information I have requested. <br /> Signature <br /> Completed by Department—Office Use Only <br /> Department: Processed By:,,,,I/ <br /> /VOW Dis LGucSI -i <br /> Method of Response: ❑ In-Person ❑ Phone 0 Mail Information Classification: <br /> Email ❑ Fax Public 0 Private ❑ Non-Public <br /> ❑ Confidential 0 Protected Non-Public <br /> Action: Approved Requested by: <br /> ❑ Approved in Part(Explain below) 0 Subject of Data <br /> O Denied(Explain below) ,Not Subject of Data <br /> Remarks or basis for denial,include statute section: Identity Verified for Private Information: <br /> ❑ Identification(DL,State ID,etc.) <br /> ❑ _compare Signature on File <br /> Personal Knowledge <br /> ❑ Other <br /> Note: MS§ 13.03,subd.3,authorizes the city to charge fees to recover costs to provide copies of data,including costs <br /> associated with searching,compiling,copying,mailing or otherwise transmitting data. Prepayment is required prior to receiving <br /> copies of data. There is no charge for inspection of data or for separating not public data from public data. <br /> Copy charges: Method of Payment: <br /> ❑ (8'/2 x 11/14") X 0.25 0 Cash <br /> (#of pages) 0 Check <br /> ❑ (11x17") X 1.00 0 Visa <br /> (#of pages) ❑ Master Card <br /> ❑ Employee Time($ /hr) X hrs <br /> (only charge if over 100 pages) <br /> ❑ 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 />