HomeMy WebLinkAboutRe: Request for data OR02i0 ADMIN25�RATIVE OFFS�ES -
INFORMATION DIS�'DATA PR CTIC�S ACT
• � �NESOTA Ga ,
• gEQl7ES�E�Z N07'E: � • T"' '" ou
A, gecruest Frequenc� - Private Data on individuals. F`e- th�
have been supplied the data and uf fQ eSZXfmon�seth nezfter �
data ize�d not be disclosed to 1'ending vr additional data 'on
� .unless .�a dispute or ac..zon is -p �
you .has been col.lected.
You �ay be reauirec to pay��zC�u�� .�os�s in �akinq,
B. zhe copies o� inLO=�zt1Or
certifying an3%or com�iling
requested. � � �r / '
/ � ,
Date of Request: �P
r '
gequester Names .
U - — City:
Ac3dsess:
� zip: � �
H�e Phone:
%S- o'Z � L�� (p O lo SBusiness:
Descripti.oa of =�°�a��n Re�este3:.
Retraester'. s Si,gnature:
BFyOW =NgORbiATION TO BE FIT.,L
IN BY DEPAR�'M�'�T OhZ�Y
sanalea sys
D ep ar�ent_
Mail Phone
gequ.est Type= —xn Pe'-"son . — —
Subjec� o= Data
Not Su:o je�� oi Data
geques�ed Sy= —
�ublic _P=iv�te
Tnfoz�a.tr.on Requested is Classified= —
Na�_�ubZi� _-rotected Non-Public
Con=idential � . _� Y��
Denied � Anproved _- - -
gecruest is: Aoproved —
Re�arks/Co�ments=
� • � � � ��'
Anthori-z ed S ignature: �/ " .
�` � _ $
x Total Due __
Fees:• eS Rate per Page
No. of Pag .