HomeMy WebLinkAboutrequest for info OROIdO ADMINISTRAT=V� OFFS�S �
r�p�2,M�TION DISCLOSURE R�Q�ST
MINNESOT� Ga DAT� PRACTICES ACT
REQUESTER NOTE: the
A, Request Frecruency - Private Data on individuals. After you
have be�n supplied the data and ouf fo eSiXfmonti�sethereafter
data need not be disclosed to Yending or additional data -on
unless a dispute or action is p
you has been col.Iected.
B . You may be required to p�Y
actual costs in making►
certifying and/or compiling
tre copies oz in�ormat=-on
requested. �
Date of Re�uest:
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Reqnester Name: �
,� �i City: �e��n` y l� �o �ti
Addr e s s: � f 7 �a �^ . 1-�}i� � <<�.
Zip: ��5 11 �
� , _ �, � �� -7 Business=
gome Phone: � -
Description of Informat�°n Requested: � .�
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Reruester' s Signature:
Bg,�,OW INgOR''iATSON TO BE FII,.LF.D
IN BY DEPARZ�NT ON�Y
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Handled By: � �'�k �`-S'
Departme.nt: '.a.
/ Mai? P. ne
Request Type: V I=� Person
Subjec� o= Data �Not Subjec� o= Data
Requested By: — `
Info=mation Requeste3 is Classified:
�=u�I.ic _Private
Nan-?ub1±.c =rotec}ed Nan-PuDlic
Conficeztial —
Denied Aporoved in Part
$equest is: � ADProved —
Re�ar3�s/Comments:
Authorize3 Signature:
,� ��,�G�, '
, = S
X Tota1 Due
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