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City of Orono 4-jM
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<br /> pInformation Disclosure Request
<br /> Minnesota Government Data Practices Act
<br /> `iArrnoac
<br /> Completed by Requester
<br /> Requests`Nae(Last First, I): lDate of Request: 02/)3 /20/q�
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<br /> Email: 1 t�LL 11 p Request Type: )In-Person 0 Mail
<br /> Wilt-tinter). kir+e �L'or-te)/.CO^'\ 0 Email 0 Fax
<br /> Street Address: Phone Number: /
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<br /> D So•Ytk S;XV. S-Free+ 1 S ./$bet 6 i a t Z- 6,s-33
<br /> City,State,Zip Co e: Signature: L
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<br /> Note: MS§ 13.05,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 /> Cop e5 t en7��re, Q cF Orono -p le ?c-Ia,�t , 1�
<br /> ( is-s-0 { /i/erA,n p/ci'Cet Orono , ltio s _ ser.
<br /> 61-c, Le - + J tin -`'ers4 6y fhes.sezler)
<br /> I have read the inf r understand the city may charge fees to provide the information I have requested.
<br /> Signature
<br /> 2c r-j/3{7 1 p74 Eb-„F � �,y{+i t,�1 }it��i��Q'�,lii ti ��n lEj �v � ir.`�c$4� . c'� ��q] �d�j
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<br /> Department: Processed By: C
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<br /> Method of Response: 0 In-Person 0 Phone 0 Mail Information Classification:
<br /> fp Email ,'Fax NC/Public 0 Private 0 Non-Public
<br /> ❑ Confidential 0 Protected Non-Public
<br /> Action: )11I Approved Requested by:
<br /> ❑ Approved in Part(Explain below) 0 Subject of Data
<br /> ❑ Denied(Explain below) C? Not Subject of Data
<br /> Remarks or basis for denial,include statute section: Identity Verified for Private Information:
<br /> O Identification(DL,State ID,etc.)
<br /> O Compare Signature on File
<br /> ❑ Personal Knowledge
<br /> 0 Other
<br /> Note: MS§13.03,subd.3,authorizes the city to charge fees to recover costs to provide copies of data,including costs -
<br /> associated with searching,compiling,copying,mailing or otherwise transmitting data. Prepayment is required prior to receiving
<br /> copies of data, There is no charge for inspection of data or for separating not public data from public data.
<br /> Copy charges: Method of Payment:
<br /> ❑ (8%x 11114") 337 X 0.25 Yr zv 0 Cash 1
<br /> (II of pages) Check 1226, r7 d'/03'Z S
<br /> O (11x17") / X 1.00 /• 00 0 Visa
<br /> (#of pages) 0 Master Card
<br /> O Employee Time($ 18/lir) X / his /&OO
<br /> (only charge if over 100 pages)
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<br /> O Other Charges(attach explanation) Received by: �J,"'�
<br /> Total Amount Due: $/OS•ZS Date:
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<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
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<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
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