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I"l i� �a..�`�ov� <br /> ORONO ADMINISTRATIVE OFFICES <br /> INFORMATION DISCLOSIIRE REQIIEST <br /> 1�IINNESOTA GOVERNMENT DATA PRACTZCES ACT <br /> REQIIESTER NOTE: <br /> A. Request Frequency - Private Data on individuals. Af ter you <br /> have been supplied the data and informed of its meaning, the <br /> data need not be disclosed to you for six months thereafter <br /> unless a dispute or action is pending or additional data on <br /> you has been collected. <br /> B. You may be required to pay actual costs in making, <br /> certifying and/or compiling the copies of information <br /> requested. <br /> Date of Request: `-7 � y �/ <br /> Requester Name: �c�,��-�,z;� �3�,�;'S <br /> , G ., _. � <br /> Address: l /�� ?'-- �A-��z-2���;s f"��, _��� City: �,cc"�/JU <br /> zip: 5� 3� � <br /> Home Phone: ���- �� �v i Business: ��� " d = � �-- <br /> Description of Information R ested: <br /> �-s � ��1 � � ��� �- P,�ov� < <� <br /> � . <br /> � � ,: r� � � ,,.;�� ' <br /> Requester' s Signature: ' i <br /> BELOW INFORMATION TO BE FILLED IN BY DEPARTMENT ONLY <br /> Department: Handled By: <br /> Request Type: In person Mail Phone <br /> Requested By: Subject of Data Not Subject of Data <br /> Information Requested is Classified: Public Private <br /> Confidential Non-Public Protected Non-Public <br /> Request is: Approved Denied Approved in Part <br /> Remarks/Co�nments: <br /> Authorized Signature: <br /> Fees: x = $ <br /> No. of Pages Rate per Page Total Due � <br />