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ORONO ADMINISTRATIVE OFFICES <br /> INFORMATION DISCLOSURE REQUEST <br /> MINNESOTA GoV=U4ENT DATA PRACTICES ACT <br /> REQUESTER NOTE: <br /> A. Request Frequency - Private Data on individuals. After you <br /> have been supplied the data and informed of its meaning, the <br /> er <br /> data need dispute or <br /> orsaction is pending or additional sed to you for six months edatat <br /> unless a disp -on <br /> you has been collected. <br /> B . You may be required to pay actual costs in making, <br /> certifying and/or compiling the copies of information <br /> requested. ) <br /> Date of Request: <br /> Requester Name:. �L_��O r _ _ <br /> Address: o r' (�t t t t <br /> City: <br /> zip: <br /> Home Phone: e 7 S - C'7C Business : <br /> � Z <br /> Description of Information Requested: <br /> C1 T <br /> r=v <br /> �77 <br /> Requester' s Signature: <br /> BELOW INFORMATION TO BE FILLED IN BY DEPARTMENT ONLY <br /> Z Handled By: <br /> Department: <br /> Request Type= <br /> In person Mail Phone <br /> RequestedY= ` <br /> B Subjec- of Data Not Subject of Data <br /> Information Requested is Classified: public Private <br /> Confidential <br /> Non-Public protected Non-Public <br /> Request is: Approved Denied Approved in Part <br /> Remarks/Comments: <br /> Authorized Signature: <br /> _ $ <br /> Fees: x Total Due <br /> No. of Pages Rate per Page <br />