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ORONO ADZ"iIN=STR�T�E OFFI�S <br /> =NFOR�IATION DISCLOSURE K�SZ�ST <br /> MSNNESOTA Ga DATA PR�C'r=CES ACT <br /> RESZUESTER NO�� oT ou <br /> A. Request FrecTuenc� - Private Data on individuals. Af t"� the <br /> have been supplied the data and uf fQ eSiXf�ontnsethereafter <br /> data need not be disclosed to y <br /> un1ess a dispute or action is pending vr additional data -on <br /> you has been �oZi e����• z�tual costs in making, <br /> B. You may be required to pay iT1L02'III�L'on <br /> certifyinc ar_d/or ���Piling ti:e copies o= <br /> requested. � <br /> - ,� � �� / <br /> Date of Request: � <br /> � �``"��_ <br /> Reqzzester Name: L-'(-��` , � t � ����� <br /> Address: <br /> �, ' LC� � �✓�� J��'�� Y <br /> z ip: `' `' � �' `� _ c� � ' _ �5 3 � <br /> j � �, _ c.� � �. _ � 3 :� � Business: <br /> � L �� <br /> g�e phone: �C' <br /> Description of Informat�on R�ueste�.: <br /> � �� �; �D � �-�',r-�-�-��� ��- 5 , <br /> �V `� ��, �__ f ��, ;'L. f� ,�l <br /> Reqtzester' s Signature: <br /> BgyOW INgORMATION TO BE FII�LED IN BY DEPARZ�NT ONLY <br /> Handled BY= <br /> D epartme.nt= <br /> r� �erson <br /> Mai? Phone <br /> Request �'ype= — <br /> ' �:. or" Data Not Sub-ject of Data <br /> Recruested BY= _Sub�e_- — <br /> Tnfo�ation Re�Bested is Classified= <br /> �ublic _Private <br /> *7or�-?u91=� =rotected Non-PuDlic <br /> Confident�al — <br /> Denied A�proved in Par� <br /> Rec�aest is: Approve^� — - <br /> Re.narks/Car�ents- <br /> Autlzorize� Sigriature: <br /> _ $ <br /> x Total Due <br /> Fe�s: a es Rate per Page " <br /> No. o= ag <br />