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OROHO ADMSNISTR.ATIVE OFFS�ES • <br /> �TFORMATSON DSSC�DA� PR �=�S �.CT <br /> • � �iS3�Iv�ESOTA GO , <br /> • g�?QUESTEK NOZ`E= <br /> A, gecrtaest Freauency - Private Data oa iudividuals. �'��e= th� <br /> have been supplied the �as a to a ouf fores�xfnon�.:nse hereafter - <br /> data ne�d not be disc1 Y <br /> �-ion is •pendiag or additional data �on <br /> . � .unless ��a dispute or ac.. . _ . . . . <br /> you .has� bee�. coll.ected. _ <br /> you may be reauired to pay��actuz.l �cos�s in �akinq; <br /> B' and/or co��iling Lhe copi.es oi inforazt�or <br /> certif ying <br /> =eauested. ' <br /> , <br /> Date of Request: J '��'.'�v�Lti�� f <br /> . - . ���� � �� 'i Y�. <br /> e: � <br /> Req'aester Nam . <br /> , � City: ��'�,,��<� i — � <br /> Ar3d.ress: ��J� S S--f�'t S '� t'7, ' <br /> � Z ig: �� `��(� �- <br /> Business: /ol yr3 3S-��� _� — <br /> S�e Phone= <br /> ormation Retrueste3:. Lr� <br /> Descript�-an af � � <br /> ��� � ' � � <br /> �,v L��v . <br /> , � <br /> Si a��e: <br /> � Rea'uester'. s 9'n PAR��N� ONZY <br /> BgLOW =NgpgMATION TO BE FII�LED IN B <br /> Handled bY= <br /> D ep art'�.e�t= Phone <br /> In persar_ Mail — <br /> gequest Z`YPe= — • — <br /> Sub jec:. o= Data <br /> Not Subject o= Data <br /> R�ques�ed By= — <br /> �fo�ati.on Req'aested is Classified= <br /> �ublic Private <br /> �ublic <br /> Nan-?uDZic _=rotected Non-- <br /> Con=idential. — . . � � � _ � Part <br /> Denied � P_�oroved n_ <br /> Recrues:t 1S: Aooroved — �— � <br /> Re�arks/Co�ents: <br /> gn�ori.ze3 Signa-tBse: � <br /> _ $ <br /> x Total Due „ <br /> Fees:• eS g�te per Page <br /> No. of Pag . <br />