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A. REOUESTER COMPLETE!lf�me 1-S) HENNE�IN COUNTY _22_ ' <br /> , ��E F NEOUEST INFORMATION DISCLOSURE REOUEST <br /> � °�q ° Minnesota Government Data Practices Ac! <br /> l S7E NAM �usc. rsc.�.1 AEGUElTEN NOTE: <br /> S� ��' C A. R�qu�st Fnou�nry—Pnrab Olt�on inC�v�Cuali.Att�r you�avt DNn�J <br /> tn�Oaa and��}orm�d of its m�aninq.tM Oata nNa not D�Oisc�os�C to y� <br /> AODRESS Irl nMO�01 � �U[TOf1th!thf���fSH Uf11t33�Ci�DUt�Of aCSiOA q D��O��q Of�Ctl�liOflll Oit� <br /> � �C �.�r �� Of�YCN hai DN/1 COtIKttC. � _ _„_ <br /> � �. MONE id nMo�a 8, You msy D�r�OwrM to D�Y tM actwl cosri of m�kmp,CMifymy tnC/or <br /> \ � �� `^,�� �C ��-� WmD�ilnq M�caP��01 intormauon nqu�ft�C. <br /> '�J Y ` J <br /> a OESGii1��ON OF TME iNFOR�TiON REOUES i ED �n f <br /> J 1 ` <br /> �sr��....,,r ��.�.. 1 5� <br /> y���,� — <br /> s oues7eR s+c.++wruaE <br /> X .. _. - •----• _ . . _ <br /> 8. DEPAATMENTIOIVISION COMPLETE �. qE0uE5T w►NO�ED 8r <br /> 6. DEP�ATMENiiD�viSiON NA►rE <br /> f, REOUESTED ilV: <br /> l AEDUEST T�'pE � <br /> p i�.q.rsa� ❑ �ta�i O P►+� p s�ei.or n»aaea ❑ Not tf+�wbj.of t��Cna <br /> ta TME iNFOR�A710N AEGUE57�0 IS Gu►SS�F�ED: 11. AEOUEST - <br /> ❑PUBUC " ❑ NO�UBUC ❑ADP��4 ❑O�n��d ,�j ApP►�'b�n D�*t(�:Ola�n m 13) <br /> � PR�yA� ❑ PpOTECTED NON-PUBLfC tt�u�NOp�ZED S�GN�TUNE <br /> ❑ CONFIOENTIAL ' X <br /> 71 pE►uctKSiCAu►iENTS�u rw�.�rna aar�y auanwo ao��ro o�n��ar+ro m�nowr�r ex��urnoi�ry d n�son.�uo r�nr�rrf orn�r r�m�rrs,cornnrnn�aoroa��ai. <br /> C. DEPARTMENT/OIVISiON COMPIETE WHEN FEES ARE ASSESSED (A rscsipred coAy ol this lorm is to Ds provided to tM requssier�ic <br /> t/me mon�y is r�ceived). � <br /> ��' �FEES:FLAT RATE • t1 ❑FEES:SPECIAL RA7E(Compl�t���0�tqtA/ortn NC 1370 wh�n oth�► <br /> x rA�n t1»fUT RATE or STANDAAD fEE SCHEDULE�s us�e.l <br /> {NO.OF P�GE51 <br /> •Sw MmM_Wnwl fa fLAT MTE Nnount <br /> I Am nc�+vW hom tM aDov�nam�G.th�amount inaicatW opP��t� my s�qnatur��n paymtnt fot <br /> prpwd�np th�mfOtmitiOn rpuKtld. <br /> TODwrS DATE <br /> 16. � pECfiIVED BY <br /> TOTAL AIMOUN7 OUE S + <br /> r00wr5 OwiE <br /> 17A. AMOUNT TO SE�EPAIO � AECErvED Sr � � � <br /> l30�o�Mt.totl!�l o.+�it0.001 = � <br /> TOOAr'S OATE <br /> t 7B. 6AW'�GE DUE � AECEIVED OY <br /> 1 <br /> ruoa+cow�a«.on a eonww/ S <br /> D. REOUESTER PLEASE NOTE iTEMS CHECXED �� " <br /> '1. � Mike checfc/money order payable to: <br /> Z. � I! mailed. rotum �ntiro form and any fees to: - <br /> MC 1506(2-8 <br /> REOUE57ER COPY/RECEIPT • <br />