HomeMy WebLinkAboutrequest for data OR02d0 ADMINISZ`RATIVE �FF=C�S
INFORMATION DISCI,OSIIRE RE4IIEST
MSNNESOTA Ga DATA PR�CTICES ACT
' gEQIIEST�R NOTE=
A, Request Frequency - Private Dat informed1 ofditssmeaning, the
have been supplied the data and
data need not be disclosed to yending or add tional edatat�on
unless a dispute or ac�ion is p
you has been collected.
g , YQu may be required to pay actual costs in making,
certifying and/or compiling the copies oz in=ormation
reguested. �
Date of Request:
10 � ��—
Requester Name: D � �! � � �
� � ./�Y City: ����'�'l�>
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Aaar�ss: �,���
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Descripti�= of I�ormation R�uested: ('C'
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� Re ester'. s Signature: �,� "r�i�l �'���`�
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BELOW INFORMATION TO BE FII�I�ED IN BY DEPARTM�?NT ONLY
Handled BY=
Departsient=
Request Type: In person
Mai1 Phone
Subjec�- o= Data Not Subject of Data
gequested By= `
Inf ormation Re�a
ested is Classified: �ublic Private
Confidential
Non-?ublic =rotected Nan-Public
gequest is:
A�oroved Denied Approved in Part
Remarks/Co��ts-
Authorized Signat�re:
_ $
Fees:� x Total Due
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