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ORONO ADMSNSSTRATSYE �F�SCES � <br /> 2NFOFtMATION DISCLOUS�UREPR�4�I�S gCT <br /> • � MSNNESOTA Ga , <br /> • gEQUES� NOZ`E: . <br /> A. geques-t Frequency - Private Data on 3..ndividuals. �ter th� <br /> have been suppliea ,�Zosed to youf foresi.Xf mon-cnse hereafter • <br /> data n.eed not be dz <br /> . � .unless `a dispute or action is �pending or zdaitional data -on <br /> you .has beein collected. <br /> you �ay be reauir�ed to pay��actual cos�s in �aking: <br /> B . zhe cogies or inf oraatior <br /> certifying and/or com�iling <br /> requested. � • <br /> Date of Request: <br /> J �� � <br /> � • , ��^. . <br /> Requester Name= \ � <br /> �D � �0� %\ „ City: � . Cl�'t--�� <br /> A.aa.=ess: <br /> � 1 �� ��., �.��1 , <br /> . s �� �3�� � � <br /> Zip: � � g � <br /> `� ��, �� S � Busines s: ` <br /> g�e Phane: � � <br /> ormation Ret_ruested:� � <br /> Descriptian af 115 � � <br /> 1��.,� �" . <br /> � ��tc�l �'� � �1.�C:'e,�V�O �Dl �� <br /> `� 7 C� - , �,� _ <br /> �4�. 1 �. � � (� <br /> � Reuueste.r'. s Signature: <br /> B�,yQW =NgORMATION TO BE FIT�LID IN BY DEPART�''NT O2T�'Y <br /> s�.alea sy: <br /> D ep art�.ent: <br /> MaiZ Phone <br /> gequest Type3 —In pe=son . — — <br /> gequested By= — <br /> Subjec� o= Data Not SuDje�� o= Dzta <br /> =�offiat:.on Reqaested is Classifie�d: <br /> �ublic =Private <br /> Naz-?ublic <br /> =rotected Nan-Public <br /> � � Confidential — . � ;n pat <br /> Denied � _ ADproved _- - <br /> gecrues�t is: Aooroved — �— � <br /> Rem.arks/Camments: <br /> Anthon-zed Signatare: - <br /> = S <br /> Fees:• X Total Due ., <br /> No. of Pages R�te per Page <br /> � � � ��..�,�.�� _ ' ! . <br /> ���� �;�' �;, , �� �` '� ��/-�,,,,,� � . <br /> �1 , � �.� G�,� �.ct� � � ��-�-.t <br /> ��,�� C�,� . <br /> � � / �/- /J7� %�f� ���y� <br />