HomeMy WebLinkAboutRe: data request ORONO ADM=NISTRATNE 0�=�S �
=NFORM�iTION DISCLODS��PR�I�S gCT
• � IS23�7PTESOTA Ga ,
• gEQUESTER NOZ'E- . -
g. Request Frequeacy - Private Data on individuals. ��er the
have been suppbeeQi�losed to youf foresixf man�:nsehreafter �
data need not
� .unless ��a dispute or ac�ion is -pending or adaitional data -on
you .has� been col.lected. � �
H. yQu may be required to .pay�'actual cos�s in making,
certif ying and/or compiling the cooies of iaf ormation
requested. -
,
Date cf Reques�t: - � � �
. - � �� ..r 7/ �K �✓ �v,.f l-.c/t�-G�
Reqaester Namez
3� I' ���� ,r� r<•t
.� � : .�_,�,�-_ City: �� .
p,ddress: �
. . s�3 s�
Zip�
a�� thone:
�� _y7� � o�1 S� Busiaess: 9�Z- �l' 7'�' ��2�
Descriptian of Iaformatioa Retruested:
.� �� l �� l 7 G s�i,�� �� �-e.
�c
� Rea-aester'. s Signature:
BgyOW ='NgORMATION TO BE FII�LF•D IN BY DEPARZ'MEZIT OI�TLY
� Handled By- �
Depart��t= �"r
Mail Phone
gequest Type= In person . — —
Not Subject of Data
gequested By= _Subjec� of Data ,
T�fo�ation Rec�a
ested is Classified: �ublic Private
Noa-?ublic =rotected Noa-Public
Canf idential _ . � ----
Denied � A�proved in_Part
ge�c�aest is� =�Proved __ --- ' . `
Rem.arks/Cammie�ts-
Aathorized Sig�'t�e: �
_ $
Fees:• x Total Due ._
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