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ORONO ADMINISTRATIVE OFFICES <br /> INFORMATION DISCLOSURE REQUEST <br /> MINNESOTA GOVERNMENT 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 /> data need not be disclosed to you for six months thereafter <br /> unless a dispute or action is pending or additional data -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 /> /44-1 <br /> ��i ter/, <br /> Requester Name: / <br /> c��o'/2 <br /> Address: > o y: <br /> Zip: . � 1 <br /> 7/ _ 5'O �/ Business: �C� --s-3'S� <br /> Home Phone: --� <br /> Descr' tion of Information Requested: �, <br /> TIP <br /> Requester' s Signature: <br /> BELOW INFORMATION TO BE FILLED IN BY DEPARTMENT ONLY <br /> Department: Handled By: <br /> person Type: <br /> In Mail Phone <br /> Requested By: Subject of Data Not Subject of Data <br /> Pqu <br /> Information Requested is Classified: <br /> Public Private <br /> Confidential Non-Public Protected Non-Public <br /> Request is: Approved Denied Approved in Part <br /> Remarks/Comments: <br /> Authorized Signature: <br /> Fees: x $Total Due <br /> No. of Pages Rate per Page <br />