Laserfiche WebLink
A. REOUESTER COMPIETE flt�ms 1-3) HENNEPtN COUNTY _ZZ_ � <br /> �1 OATEOFRECUEST INFORMATION DISCLOSURE RE�UEST <br /> 3u�nC �5� ���ti' Minnesota Government Data Practices Aci <br /> 2. aEGUESTE NAM �wc rs�•M.� RECUEETE*MOTE: <br /> �AGK �• �l�('��� A. Requnt fnqu�nry—Pnwte Dan on indiv�tluals.Ah�r you naw be�n y <br /> m�tlau and inform�d of ia m�amnq.tM data nHa not D�Oiu�os�a to y� <br /> AODFESS�rl n«ow� � ��s iifOflth�thft��ftN Y�It3i�O��A���O►iRiO�ii pMtl�nq Ot�CCtdOnil O�t� <br /> ZG�Q g �amq�uc� 1 r _ anf,lo�z. «,,���o..,,�o�,.��a. � _ -_ <br /> s. MONE r��nMo�c� -y B. You may b�rpu�r�C to pay t��acfual cosb Of m�kinp,C�rti}y�nq andor <br /> l�I�tu�� /�'Irnn����� J-�J" 71�� !l�L� � f L� 7C•J� eomo���np m�CaO�es of informaUon r�0uest�C. <br /> a pESCR�PT�ON OF TME iNfORW.7ION NEOUES�ED <br /> If�+��c-c� � n� ������ ��,�1�a� o�l c.�.��. � ,,� � - <br /> �3� �'��co <br /> �C� G�T`�--� �e�r,-.{� /<7 v�"� u ��l7 h�t�� <br /> S. NEO STE��'+++�TUR „ _ <br /> x .. _. _ .-–'--- _ . <br /> 8. DEPARTMENT/O1VIS10N COMPLETE 7. fiE0uE5t ruHOLE r � <br /> •. DET�QTwENTiDiviSiON N�wE <br /> � + r'i�� <br /> ''� �` f. REouESTED sr: <br /> {, REOUEST TYP£ � <br /> ❑ In-p�rson ❑ Mait ❑Phon� ❑SuDj.ot eM oaea ❑ hlot m�suoi.ot tn•ana <br /> 10. TME iNFORwA710N REOUESTED IS GV.SSiFiED: 17. REOUEST - <br /> ❑PUBUG ` ❑ NON-?UBUC ,�AD��b ❑D�n��d ���D���n D�n t�:01am m 13) <br /> � pRIVA7E ❑ PRGTECTED NON-AUBLtC t2�u�.+OAi S�GNwTUpE <br /> ❑ CDNFIDENTIAL x �� '� ,��'� <br /> 11 RfIJARKS/CAYMENTS fll nO�inO O�I N Gu�d»O i0 u ro O�nr�Ccrs ro�M r�Owttp Gn�utnOnfl'o�nat A40 MI�I Nr OtM��Y�i.COTrMnA IOG��W��NI. <br /> y(�Z..� ��.J�rt`-J`�(�-rC c�i��`� <br /> C. DEPARTMENT/DIVISiON COMPl.ETE WHEN FEES ARE ASSESSED (A rscsipisd caAY o1 thrs lorm is to bs provided ro tM rsqussrer eic <br /> tim�mon�y is r�csive0). <br /> ��' �FEES:FLAT RATE � �� ❑FE£S:SPECIAL RATE(Compi�t���4�tucn torn+MC 1310 r'�1M O[AK <br /> x tAan tM fi.A7 RATF or STANOARD Fff SCNEDULE ia us�O•1 <br /> INO.OF P�GESI <br /> ♦Sw�Gnrn.Wnuv fa FLAT 11ATE Nno�nc <br /> I htv�ncnvW from tn�acw�namW.tM amount ina�qtW oPP��t� my��pnatur��n paym�nt for <br /> providmp tM mtormauon nquested. <br /> 7oDwrs D�TE <br /> t6. � RECEIVED 9Y <br /> TOTAL ANOUNT DUE S � <br /> TOCwrS OwTE <br /> 17A. AMOUNT TO OE�EP�IO � iiECE1VED SY � - � <br /> rso�o��rr.raN d o.w ts0.00/ S � <br /> TODwr'S OwTE <br /> i78. �W'�CE DUE � PIECfIVED S� <br /> 1 <br /> �uoo�con�a«�on a eoor�o� S <br /> D. RECUESTER PLEASE NOTE ITEMS CHECXED " " <br /> '1. p Make check�money order payable to: <br /> 2. 0 If mailed. retum entiro form and any fees to: • <br /> MC 1506IZ-8 <br /> REQUESTEA COPY/RECElP7 • <br />