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INFORMATION DISCLOSIIRE RE4IIEST
MINNESOTA GO DATA PRACTICES ACT
REQIIESTER NOTE:
A, Request Frequency - Private Data on individuals. After the
have been supplied the data and infor�ed of its meaning,
data need not be disclosed to yending or add tional edatat�on
unless a dispute or action is p
you has been collected.
H, You may be required to pay actual costs in making,
certifying and/or compiling the copies of information
requested.
Date of Request: I�r 1 �� j�
Requester Name: �, ! ( '' S�"`'�
Address:
�� ��...0 <...., s r. city: 7�a.. I�. /1 ,
zip- s S3� (
Home Phone: �i ?� ,n `r S
Business= � ��'`� 31�
Description of Information Requested:
�`���,;f ��� ��f -
Reqaester' s Signature:
BELOW INFORMATION TO BE FII.LED IN BY DEPART�NT O�TI'Y
Handled By:
Department:
In erson MaiZ Phone
Reqnest Type: P
R ested B Subject of Data Not Subject of Data
equ Y=
Inf ormation Requ
ested is Classifie�: �ublic Private
Confidential Non-?ublic -rotected Non-Public
A roved Denied Approved in Part
Request is: PP
Remarks/Comments:
Authorized Signature:
_ $
Fees:� x Total Due
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