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INFORMATION DISCLOSURE REQUEST
MINNESOTA G40VERIu6ENT DATA PRACTICES ACT
REQUESTER NOTE - Private Data on individuals. After you
A. Request Frequency
the
have been supplied the data and of foremeaning,of its
six months thereafter
data need not be disclosed to you
or additional data -on
unless a dispute or action is p
you has been collected. actual costs in making,
B . You may be required to paY
compiling the copies of information
certifying and/or
requested.
Date of Request:
Requester Name: N4 ;. z�b
Cityfug
Address:
�Ar h�A oc ,psi 3 :
Zip: SOLI 0
game Phone:
413 1 b'I Business.
Description of Information Requested
l
Requester' s Signature:
:
BELOW INFORMATION TO BE FILLED IN BY DEPARTMENT ONLY
Department: �f Z
Handled By= *_
Request Type: v4- In perscn
Mai? Phone
Requested By: —
Subject of Data V Not Subject of Data
�ublic _Private
lnformation Requested is Classified: �_-
_Confidential
Non-Public :rotected Non-Public
Request is: Approved
Denied Approved in Part
Remarks/Ccmatents:
Authorized Signature:
x Total Due
Fees: g Rate per Page
No, of Page