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ORONO ADMINISTRATIVE OFFICES
INFORMATION DISCLOSURE REQUEST
MINNESOTA GOVERNMENT DATA PRACTICES ACT
REQUESTER NOTE: individuals.. After you
A. Request Frequency - Private Data on indou
have been supplied the data and informed ix of themtshseahereaft
data need not be disclosed yending or additional data -on
ou unless a dispute or action is p
you has been collected. actual costs in making,
B. You may be required to pay
certifying and/or compilitre copies of information
ng
requested.
Date of Request: ��� ��
Requester Name: C
Address: /
.(R-)r- dam° 0,4,--) 4 city: v /2
zip: ______,ELLL____________
Business
gee Phone:
Description of Information Requested:
Requester` s Signature:
BELOW INFORMATION TO BE FILLED IN BY DEPARTMENT ONLY
Handled BY=
Depar gent
In person
Mail —phone
Request Type: —
Retrnested By: _Subject of Data
Not Subject of Data
Information Requested is Classified:
Public _Private
Confident'al
Non-Public Protected Non-Public
Request is: Approved __
Denied Approved in Part
Remarks/Comments:
Authorized Signature:
x Total Due
Fees: Pages Rate per Page
No. of