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INFORMATION DISCLOSURE REQUEST
MlNNESOTA GOVEpMdENTDATA PRACTICES ACT
REQUESTER NOTE-
A. Request Frequency - Private Data on individuals. �=te= the
:ace been supplied the data and informed
f fo esixf months thereafter
hereafter
data need not be disclosed to you
or additional data -on
unless ='a dispute or action is 'p
you .has' been collected. a actual costs in making;
B . you may be required to pay _
certifying and/or compiling the copies or in=oraatior_
requested.
Date of Request:
Requester Name:
City:
Address: C�
Zip:
Business:
game Phone:
Descr Dt-ion f Tlif o=at-ton R
ested:.
gequester'. s Signature:
BELOW INFORMATION TO BE FILLED IN By DEPARTIx_7NT C'Zy
Handled By:
D ep aytment:
Mail —Phone
Bequest Type= _In Person • —
Not Subject- of Data
R
equested By: Subject of Data
—
--public
_Private
I_nfojcat_ on Requested is Classified: —
Non-Public
protected Nom-Public
_Confidential —
eDenied Aoprovel int
_Par
Request is: Aooroved — 1
Remarks/Cents:
An pori=ed Signature:
Fees: x Tota? Due .,
No. of Pages Rato per Page
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