HomeMy WebLinkAbout02/18/2000 -info disclosure request � OR0210 ADIriTNIS�RATIVE OFFI�S
2NFORMATION DISCLOSIIRE RE4IIEST
2iZNNESOTA Ga DATA P��CTSCES ACT
' gEQIIESTER Na�E: .
A. Request Frequenc� - Private Data on individuals. A�te�' Y°u
have been supplied the data and infor�ed of its meaning, the
data need not be disclosed to you �or six montns thereafter
unless a dispute or ac�ion is pendiag or additional data -on
you .has been collected.
B, you may be reauired to pay actua? costs in making,
certif ying and%or com�iling the copies oi inLOr�zt1On
requested. �
Date of Request: � � � /
` � , �' � -
Requester Name=
citY: �-� '
Address:
Zip- ��_�% /
�'S `-���— Busines C�j D�� -
gome Phone: � ._ ,
ested: ' �
Description of Information Requ ^ �
, .
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�!�':
Recraester'. s Signature: �� �
BgyOW II7gOF2MATIQN TO BE FI?�L IN BY DEPARTMENT ONLY
Handled By:
Department=
Request Type: _In Persan .
Mail Phone
Subjec= of Data Not Subje�� or Datz
gequested By= `
Inf ormation Requ
ested is Classified: ?u�I.i� Private
Confidential Non-�ublic �rotected Non-Public
Aporoved Denied Approved in_Part
gequest is: _ —
Remarks/Comments.
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Authorized Signatur�:
_ $
Fees:� X Total Due ..
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