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VA <br /> ~City of OronoNp <br /> Information Disclosure Request <br /> Minnesota Government Data Practices Act s� <br /> S"k BHOPQ <br /> Completed by Requester <br /> Requester Name(Last First,MI): Date of Request: <br /> Hill <br /> Email: Request Type: El In-Person ❑ Mail <br /> t R"tin I Lehi ❑ Email ❑ Fax <br /> Street�A,cadre Vl l`UN i�V Phone Number: 7V n q <br /> _ �/\�� <br /> City,State,Zip Code: 0 Signature: V � <br /> a K41,J 5S 1I L,, <br /> Note: MS§ 13.05,subd. 12,persons may not be required to identify themselves,state a reasoA for,or justify a request to gain <br /> access to public government data.A person may be asked to provide certain identifying or clarifying information for the sole <br /> purpose of facilitating access to the data. <br /> Description of the Information Requested: <br /> rc f ►tGt�V��. Gh (�� IZ> 2n GIS C , <br /> I have read the information on this form and understand the city may charge fees to provide the information I have requested. <br /> I �' <br /> Signature <br /> Completed by Department— '�I <br /> Department: Processed By: Q - Y S <br /> Method of Response: )D In-Person ❑ Phone ❑ Mail Information Clas 'fication: <br /> ❑ Email ❑ Fax Public ❑ Private ❑ Non-Public <br /> �j Confidential ❑ Protected Non-Public <br /> Action: Approved Re uested by: <br /> ❑ Approved in Part(Explain below) Subject of Data <br /> ❑ Denied(Explain below) Not Subject of Data <br /> Remarks or basis for denial,include statute section: Identity Verified for Private Information: <br /> A Identification(DL,State ID,etc.) <br /> ❑ Compare Signature on Fite <br /> ❑ Personal Knowledge <br /> ❑ Other <br /> Note: MS§ 13.03,subd.3,authorizes the city to charge fees to recover costs to provide copies of data,including costs <br /> associated with searching,compiling,copying,mailing or otherwise transmitting data. Prepayment is required prior to receiving <br /> copies of data. There is no charge for inspection of data or for separating not public data from public data. <br /> Copy charges:es: - Method of Payment: <br /> ❑ (8%:x 11/14") X 0.25 ❑ Cash <br /> �#of pages) ❑ Check <br /> 1�1'(11x17") _X 1.00 .00 ❑ Visa <br /> (#of pages) Master Card <br /> ❑ Employee Time($ /hr) X hrs <br /> (only charge if over 100 pages) ^ <br /> ❑ Other Charges(attach explanation) eiv d Y 1Vnl <br /> Total Amount Due: a Date: "-2L <br /> This request will be reviewed by staff and the requester will be provided an estimate of charges prior to copying. <br /> If mailed,return form to: City of Orono,P.O.Box 66,Crystal Bay,MN 55323 <br /> City of Orono, 2750 Kelley Parkway, Orono,MN 55356 <br /> Phone: 952-249-4600 •Fax: 952-249-4616• Website: www.ci.orono.mn.us <br />