HomeMy WebLinkAboutData request ORONO ADMSNISTRATIYE OFF2CES
2?�IFORM�TION DISGLOSURE RE4IIEST '�
IiZNNESOTA Ga DATA PR�ICTICES ACT `'�� �P
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' gEQIIESTER NOTE:
A, Request Frequency - Private Data on individual.s. After yocf�.
have been suppl.ied the data and inforuted of its meaning,
the
data need not be disclosed to you for six months thereafter
unless a dispute or action is pending or additional data -on
you has been coll.ected.
B, you may be reQuired to pay actual costs in making,
certifying and/or coutpiling the copies o= iniormation
requested. �
Date of Request: �� � �� � �
� �, �/ -� � �/5�/
Requester Name: - � � .
�j�� 'j �; �City:
Address:
Zip: �5�� � �: _
Hcrme Phone s � �� �- ���� Busines s:
escription of I ormat'on Reuuested:
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� ��� � � �
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Requester: s Signature:
BELOW INFORMATION BE FII�LED IN BY DEPARTMENT ONLY
Handled Bys �,v�
Department: �� G
Request Typez ;� In person Mai1
Phone
gequested By= Subjec� o= Data �
Not Sub7ect of Data
.�� ?ublic Private
Inform,ation Requested is Classified: —
Confidential Non-?ublic =rotected Non-Public
„�' Approved Denied Anproved in_Part
ge�uest is: —
Remarks/Co�aents:
Authorized Sigaature: 1
� _ $
Fees:• x Total Due
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