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ORONO ADMINISTRATIVE OFFICES <br /> INFORMATION DISCLOSURE REQUESTS ACT <br /> MINNESOTA GOVTDATA <br /> REQUESTER NOTE: you <br /> A. Request Frequency - Privateindividualitssmeaningr the <br /> have been supplied the dataand informed of <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. a actual costs in making, <br /> B, You may be required to pay <br /> copies of information <br /> certifying and/or compiling P <br /> requested. <br /> Date of Request: /---/3- 9,5 <br /> i <br /> Requester Name: (�', �-, / / <br /> Address <br /> /X 3 Gl l.ea_ r C, City: C_ X -CIIC _� <br /> Zip: <br /> Home Phone: <br /> Cf'? 5 - -6 Business: <br /> Description of Tnformation Requested: 01'11,- C ( Se i;r .etc. <br /> Requester' s Signature: Ab.- <br /> BELOW INFORMATION TO BE FILLED IN BY DEPARTMENT ONLY <br /> Handled By: <br /> Department: <br /> Request Type: __In person <br /> Mail Phone. <br /> Requested By: <br /> Subject of DataNot Subject of Data <br /> Tnformation Requested is Classified: <br /> Public Private <br /> Confidential <br /> Non-Public Protected Non-Public <br /> Request is: ApprovedDenied Approved in Part <br /> Remarks/Comments: <br /> Authorized Signature: <br /> Fees: Pages <br /> No. of ages Rate per Page Total Due <br />