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City of Orono �otio. <br /> Information Disclosure Request '� 1 <br /> Minnesota Government Data Practices Act <br /> Completed by Requester ae..ii,eioin (0ii- / f4lin 5 o rn <br /> Requester Name(Last First,MI): rDatetof Request: 02/4y15,CMOI z ' <br /> Email: � Request Type: ❑ In-Person ❑ Mail <br /> 00.-r00-161.- Itt rl ep//) • Ll 5 email 0 Fax <br /> Street Addr ss: /` Phone Number: <br /> 4x000 G0ve//IM2n Ce.I-/-6r &/ -3L/S- o o <br /> City,State,Zip Code: , Signature: <br /> �n2� <br /> NL�✓ Po��s, i'tA s� / 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 /I.. <br /> Department: Processed By�O�a-- �i�V�SC-i/Z <br /> Method of Response: 0 In-Person 0 Phone 0 Mail Information Classification: <br /> Email ❑ Fax Public ❑ Private ❑ Non-Public <br /> O Confidential ❑ Protected Non-Public <br /> Action: Approved Requested by: <br /> ❑ Approved in Part(Explain below) 0 Subject of Data <br /> ❑ Denied(Explain below) AC-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'/s x 11/14") X 0.25 0 Cash <br /> (#of pages) ❑ Check <br /> ❑ (11x17') X 1.00 0 Visa <br /> (#of pages) 0 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 />