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OROIIO ADMINIS�R.ATSYE OFFSCES •
2NF'ORMATION DISGLO�S��PR�I�S gCT
• � ISSNNESOTA GO ,
• gEQUES��R NOZ`E= ` • . '
• - Private� Data oa individuals. Afte'-" Yau
A. gequest Frequenc�
t e
have been supplied the data and uf fQ es�°fmontase�eafter •
data need not be disclosed ta 1'eadinc or additional data -on
� � .unless :�a dispute or ac�ion is -p . � . �
�� you .has� been collected. . � �
you may be reauirea to •pay��actua�lies�sor in orm tian
B. the co_ .
certifying and/or com�iling
requested. O
est: 3 5 ' V '
Date of Requ �
. . G. _ -- �
Requester Name: �fp � •
. City: � ���t b i
p,.8dress:
. Zip: ��`��-.�r � .
Ha,me Phone z (��15��
� _ Business: ��i��l ��1 -��Uy
Descrip
tion of Inf ormation Rea_'uested:. t��-v
� i .
� gecruester'.s Signature:
BgyOW INgOF�iATION TO BE FIIaLID IN BY DEPAR2�.'NT O�IT'Y
Haadled BYs
Departmen't=
Mail Phone
gequest Type= - 2n person . — —
geques�ed By= Subjec:. of Data
Not Subjec� of Data
Pu,blic Private
�fo�cation Reqaested is Classified: __ --'
Non-?ublic ,__�r�tected Non-Public
Confidential _ , . � ' _n Part
Deniea � A�proved __ �
gequest is: Agoroved — -- � �
Remarks/Co�e�ts: .
Anthorized Signature: •
= S
Fees:• X Total Due ,.
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