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� <br /> � City of Orono ��'p � <br /> Information Disclosure Request <br /> Minnesota Government Data Practices Act �� � <br /> - kY <br /> Com leted b Re uester � <br /> ester Name(L�Firs � ,^� Date of Request: � �� �� <br /> � (� � <br /> ail: /��� Request Type: ❑ In-Person ❑ Mail ', <br /> V S� �Vi`Y�• IiWYY� Einul ❑ Fax � <br /> eet dd ss:„;y_ Phq+�e�,�t ber, f <br /> ,�7'4 r (.`� <br /> C,iz3� State,Zip Code:\ m r� S� <br /> ,�_rT:� <br /> Nou: MS § 13.05,subd 12,persons may not be required to identif'y themsalves,state a reas for,or justify a request to gnin <br /> access to pnblic government datA.A person may be asked to provide certain idenrifying or clarifying information for the sole <br /> purpose of facilitating access to the data. <br /> Descrtption of th Information Requested: ' <br /> 6 � �� � <br /> ., ; <br /> L�Vt,e c i ; <br /> � <br /> I have read tlle info,rm ti n o this form snd understand the city may charge fees to provide the information I have requestod, <br /> , �ti�- <br /> ature <br /> � ... � :I � - ���N� y �4 .!Jf <br /> �Com '�e� g e airtm �, �ffice Us�=. �'f,� � �� �xf� 3� �5,^` ,a r!�';. <br /> � <br /> Department: Processed By: � � <br /> m i►� <br /> Method of Response: O ln-Person � Phone O Mai! Information Classifieation: <br /> 1(�Em¢il ❑ Fax �Public � Private � Non-Public <br /> ❑ Confidential O Protected Non-Public <br /> Action: ❑ Approved Requested by: <br /> ❑ Approvad in Part(�xplain below) ❑ Subject of Dattt <br /> ❑ Denied(Explain below} ❑ Not Subject of Data <br /> Remarks or basis for denial,include statute sectinn: Identity Verified for Private Information: <br /> ❑ Identification(DL,State TD,etc.) <br /> ❑ Compare Signatute on File <br /> ❑ Personal Knowledge <br /> ❑ Other <br /> Note: IviS§ 13.03,subd.3,attthorizes the city to charge fees to recover cosis Co provi�e copies of data,inclucling costs <br /> ussociated with seatcl�ing,compiling,copying,mailing or otherwise transmitting data, Prepayment is rec�uired prior to receiving <br /> copiec of data. There is no chazge for inspection of datp or for separating not public dxYa fram public data. <br /> Copy,charges: Z5 2/ Method ofPayment: <br /> m'�a izX ir�ia°�> I D � x o.as � ❑ c�n r, <br /> (#of pages) � Check -µ-�o b 6 D� <br /> ❑ (J Ix17") X 1.00 ❑ Visa <br /> (#of pages) ❑ Master Cflrd <br /> �'Employee Time($ ��/hr) X � hrs � .�� <br /> (only charge if over 100 pages) <br /> ❑ Other Charges(attach explanation) 12eeeived by: �_ • � <br /> � (lI�Q� <br /> Totfll Amount Due: $,��y Date: <br /> - Z-I <br /> This request will be reviewed by staff and the requester will be provlded an estimate of charges prior to copying. <br /> If mailed,rehirn form to: City oEOrono,P,O.Box G6,Crystal Bay,MN 55323 <br /> City of Orono,2750 Kelley Parkway, Orono,MN 55356 <br /> Phone: 952-249-4600 •Fax: 952-149-4G1 G • Website: www.ci.orono.mn.us <br />