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OROl`IO ADt�i�72STRAT=VE OFFSCES • <br /> SI�TFORMATION D=SQ'DATA PR CTSCES gCT <br /> • � IiTI`s'Iti�ESOTA Ga , <br /> • gEQUES�FFt NOZ`E= . <br /> g..auest Freauenc� - Private Data on individuals. ��e= th� <br /> A. � . <br /> h�Qe been supolied the data and Quf fo esixfaon�set�e e�ter <br /> a�tz need not be discl.osed ta y <br /> . � . .unless :'a dispute or ac�ion is �pending or additional data '°n <br /> .� � you .has� bee� collectea. _ <br /> you may be reauired to pay��actual cos�s in �akinq; <br /> B certi.fying and/or co�piling the cooies o� inforrsztion <br /> reauested. 12 • ' <br /> est: � � <br /> Date of Requ - �� <br /> . • <br /> Name: �� ��- � � • <br /> Reguester . � <br /> � , / C3.ty: ' �' <br /> �� <br /> �r3dress: �� .. � ��`�1�ii� � � � <br /> � �� �� ������� <br /> Z�n: j��- �D� <br /> B�;�ess: <br /> H�e Phane= <br /> t.ion of 2nf ormation Reaueste3:. <br /> Descrip � , <br /> ������}��'2� . ' <br /> . �� � 4./ <br /> a��:e: � <br /> � Reuaes�er t s Siga T OZ�Z,Y <br /> Bp�,OW =NgOR�iATIOt� TO BE FII�LE� IN BY DEPAR�''N <br /> � �s,�, <br /> ��� 1��'`"' - HaIIC11.�d'. Fiy: <br /> D epa�"►���= phone <br /> .- Yn pe_son Mai1 — <br /> R��est Type= — • _.-- <br /> g�ques�ed Sy= —Subjec� oi Data '" <br /> Not Sub3ect os" Dat2. <br /> �fo�a�on Reqaested is Classifi�= <br /> f�u.oZic �_Przvate <br /> public <br /> Noa-�u�l�-c =rotected Non-- . <br /> Con=idential — , � � . _ . P�� <br /> Denied � A�proved �_ <br /> gersuest is: �� Agproved _� � <br /> , <br /> ����-.����,�_�� <br /> gPm�i'ks/Caurments= " , „ . <br /> � � �; ; , <br /> C;'�L, <� �'��.i' /\ c"�.�='� �! �:i �-.� <br /> � <br /> . e: OL�t/iZ� • <br /> ga�hori.zed Signat.ur - $ <br /> x Tota1 Due ., <br /> Fees:• _� eS Rate pe= Page . <br /> No. of Pag . <br />