HomeMy WebLinkAboutInfo disclosure request ORONO ADMINISTRATIVE OBF=CES
INFORMATION DISCLOSURE ATA PREQUEEST CES ACT
MINNESOTA GOVERNMENT
REQUESTER NOTE:
A. Request Frequency - Private Data on individuals. After the
have been supplied the data and informed
ediofxmits.hseaninghere, the
actiondata need not be disclosed to you
or additional data -on
.unless .`a dispute or is 'p
you has been collected.
You may be required to pay actual costs in making,
B . the copies of information
certifying and/or compiling
Zequested.
Date of Request: ��
Name: •
:*s17tkrAioIM/'
vim
` >AO, / SCity:
Address: '
Zip: .3 . � , _ 7
Business
gee Phone:
Description of Information Requested:
•
•
•
Requesters Signator
e- AllffiffrirdWillillillir
BELOW INFORMATION TO BE FILLED IN BY DEPARTMENT ONLY
Bnt-
Department: Ll.yz
Handled By:
' / Mail Phone
Request Type: Y In person .
Requested By:
Subject of Data _ _Not Subject of Data
Public _Private
Information Requested is Classified:
Non-public Protected Non-Public
_Confidential -- in Part
Request is: =Approved
Denied Approved
Remarks/Camments:
•
Authorized Signature:: ei � .
= S
Fees: x Total Due
No. of Pages Rate per Page