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OROliO ADMINISTR.ATNE OFFI�S <br /> II�Tk'ORMATIQi�'. DISCLOSIIRE REQII�ST <br /> MZ�NNESOTA Ga DATA PR.ACTICES �,CT <br /> gE4�ESTLR NOTE: on indivi3ua?s. After you <br /> A, Request Frequen�y - private Data <br /> the <br /> have been supolied the data ar_d uf fo esi�=�on�setheneafter <br /> data need not be disclosed to y <br /> � unless a dispute or ac�ion i.s per�ding or additional data �on <br /> you has been coZ1ected. ��tu� Z �osts in �naking, <br /> B . You may be recuired to paY <br /> certifying and/or corr�piling the copies o= inro�mation <br /> requested• c � <br /> est: �i ,i ti i �i � L <br /> Date of Requ � <br /> • � - <br /> Requester Name: � <br /> 2 51-c�� city: ��2o1�L CL <br /> A.ddress- 1 � S �^=/ � tiL s I� /2 <br /> ZiP- <br /> Business - <br /> g�e Phone: <br /> Description of Informati.on I�Zecruested: � � L C�� <br /> � � 2 �2� L� � � <br /> L(�f - � �.1. <br /> .9`�' <br /> Reruestar` s Signature: <br /> BgypW INgOgMATI0�7 TO BE FI�� I� BY DEPARZ'�'-�T ONZ�Y <br /> Ha.�dled By= �' `�d� <br /> Departme�t: �� 2-. <br /> � Mai.� Phone <br /> Request Types �_Tn oe=son <br /> rlot Sub j ect of Data <br /> Sub j ec� o= Dat� �._ <br /> Retruested P;y: __ <br /> �_.,.�Ti� �,-; va�.e <br /> �__ __ <br /> Tnfo�ation Recaes�ted is Classified: auDlic <br /> �ubl.;c =rotec_ed Non-- <br /> Conf�de�tial Nor�-- <br /> — �e�ie� Aporoved in Fart <br /> $equest is: A�orove3 — <br /> Remar�s/Co�ents: <br /> Authorize� Signatnre: <br /> = S <br /> x Tota1 Due <br /> Fees: g Rate Pe= Pag� �- <br /> No. of Pa es <br />