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SI�TFORMATION D=SQ'DATA PR CTSCES gCT
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g..auest Freauenc� - Private Data on individuals. ��e= th�
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h�Qe been supolied the data and Quf fo esixfaon�set�e e�ter
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you may be reauired to pay��actual cos�s in �akinq;
B certi.fying and/or co�piling the cooies o� inforrsztion
reauested. 12 • '
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Date of Requ - ��
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Bp�,OW =NgOR�iATIOt� TO BE FII�LE� IN BY DEPAR�''N
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public
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ORONO ADMTNISTRATSVE �FF=�S -�''� gQ i .� , ,
23�TFORMATION DISCLOSIIRE REQUEST
. Ii�NNgSaTp, Ga DATA PR�CTICES ACT
• gBQIIES��FZ NO�E= .
A. Reauest Frequency - Private Data on individuals. Afte= Y°u
have been supplied the data and inforued of its meaning, the
data need not be disclosed to yending vr ada tionaledatat-on
�unless a dispute or ac�ion is p
you .has been collected.
g, you may be reauirec to pay actual costs in making,
certifying and/or co�cpiling the copies oi information
requested. •
Date of Request:
Y , r 1 �— 1
Requester Name? .
( Cit QronJ
A.ddreSS: / � 6 �iJl.s-�- �t �- n d %� y:
Zip: S� 3 � � .�-� � _� �. �-.�,,,�
HQme Phanes
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Description of Inforraation Reaueste3: � � � ( '
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Reuuester'. s Signature:
BELOW SNFORMATION TO BE FII.LED IN BY DEPAR�NT ONLY
Handle3 By:
Department:
Request Type= In person
Mai1 Phone
ested B Subjec� of Data Not Suhject of Data
Re�qu Y= `
I�o�ation Requ
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Conf idential
Non-?ublic =rotected Non-Public
A�proved Denied Approved in_Part
ge�uest is: _ —
Remarks/Camm.ents:
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Anthorized Signature:
_ $
Fees:- x Total Due _.
No. of Pages Rate per Page ..