HomeMy WebLinkAboutinfo request ORONO ADMSNISZ�tATNE OFFSCES
23`TFORMATION DISCLO�S�UREPR 4�I�S �CT
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• �LEQIIEST�R NOTE- .
A. geQuest Freque:�cy - Private Data on individuals. �te= the
have been supplied the aata and ouf fQ esixf�on�se�ereafter �
data ueed nat be disclosed to y
�unless �a dispute or ac�ion is pending vr additional data -on
you .has been collected.
H. you may be reauired to pay actual costs in �aking�
certifying and/vr com�iling the copies o= in=orivation
requested. •
Date of Request:
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Requester Name? �- � •
. City:
Ar3dress:
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Descript=-on of ���a�'�n Re�ested:
Reuueste.r'. s Signature:
BEI,OW S27gOR�`�1ATION TO BE FII�LE� IN BY DEPARTI�NT ONLY
Handle3 sy-
D ep art��t=
Mais. Phone
geqaest 7.'ype� _In Persan . — —
gecsues�ed By: —
Subjec� o= Data Not Sui�ject o= Data
�ublic Private
Tnfosmation Reqaested is Classified: _
Non-�ubl.ic -rotected Non-Public
Con=idential —
Aporoved Denied P_aproved in_Part
gequest is: _ —
gemarks/Camments:
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Anthorize3 Signat�re:
_ $
Fees:• X Total Due ._
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