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OROIdO ADMINISTR.ATIV� O�S�S <br /> rNE'OR�SATION DISCLOSIIRE REQU�ST <br /> MINNESOTA C,a DATA PR.ACTICES ACT <br /> REQIIESTER NOTE= �- on individuals. After you <br /> A, Request Frequency - Private Da�a <br /> the <br /> have beAn supplied the data and ouffo esixfmontnsethereafter <br /> data need not be disclosed to y <br /> ute or ac�ion is pending or additional data -on <br /> unless a disp . <br /> you has been collected. <br /> vou may be required to pay actual costs in making, <br /> B . - t�e copies or informatior- <br /> certifying and/or compiling <br /> requested. � <br /> _. <br /> "� ;� <br /> -, �_� <br /> Date of Re�uest: � ' � ` �, <br /> ' � k a ,' _ ---�%�,,/� � �c„'��- <br /> ester Name= �` i ~''�� �. . � <br /> Reqn �i� <br /> , � <br /> __ �� �ty. ����-��: � <br /> p,ddress: <br /> ' �/ "' )/c��-�/ � �-- <br /> Z1D- � `i '`' �� ��� r �i - �`�� � <br /> , _ <br /> $LIS1S1eSS- > � � <br /> ;�% �'� _ / - %=c' <br /> H�,e Phone: ' ' '' � �'�� � <br /> , �� <br /> Description of Znformation Rec�ested: <br /> <�� � � > ,���� ,�, � �=�� <br /> „ , � - <br /> i'/� � <br /> _ i- ` ._��,� `�,; <br /> ature: ,���� ��, ; <br /> Re�uester' s Sign _ _' <br /> Bg�,OW =Z7gOgMATION TO B�: FII.I�E� IN I�Y li�PAR�''�''�T ONLY <br /> i (� � <br /> � � 2 Handled By: <br /> Depar�tme.nt: <br /> � Mai? Phone <br /> Request 2`yPe= <br /> In person <br /> Su�jec� o= Data <br /> �_Not Subject of Data <br /> Rec�uested By= — <br /> Information Requestezi is Classifie�d: <br /> ��ublic _PT=-vate <br /> Nor�-?'sbZ=� =rotected Non-PuDlic <br /> Consident�al __ <br /> �� Denie� Aporoved in Par� <br /> ge�uest is: Approved <br /> Re�ar�cs/Ca�nents: <br /> / <br /> atnre: / ,�� <br /> Authan-zed S19a �,, <br /> _ $ <br /> X Total Due <br /> Fees: g Rate Pe= page �- <br /> No. of Pa es <br />