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ORONO ADMINISTRATIVE OBF=CES <br /> INFORMATION DISCLOSURE ATA PREQUEEST CES ACT <br /> MINNESOTA GOVERNMENT <br /> REQUESTER NOTE: <br /> A. Request Frequency - Private Data on individuals. After the <br /> have been supplied the data and informed <br /> ediofxmits.hseaninghere, the <br /> actiondata need not be disclosed to you <br /> or additional data -on <br /> .unless .`a dispute or is 'p <br /> you has been collected. <br /> You may be required to pay actual costs in making, <br /> B . the copies of information <br /> certifying and/or compiling <br /> Zequested. <br /> Date of Request: �� <br /> Name: • <br /> :*s17tkrAioIM/' <br /> vim <br /> ` >AO, / SCity: <br /> Address: ' <br /> Zip: .3 . � , _ 7 <br /> Business <br /> gee Phone: <br /> Description of Information Requested: <br /> • <br /> • <br /> • <br /> Requesters Signator <br /> e- AllffiffrirdWillillillir <br /> BELOW INFORMATION TO BE FILLED IN BY DEPARTMENT ONLY <br /> Bnt- <br /> Department: Ll.yz <br /> Handled By: <br /> ' / Mail Phone <br /> Request Type: Y In person . <br /> Requested By: <br /> Subject of Data _ _Not Subject of Data <br /> Public _Private <br /> Information Requested is Classified: <br /> Non-public Protected Non-Public <br /> _Confidential -- in Part <br /> Request is: =Approved <br /> Denied Approved <br /> Remarks/Camments: <br /> • <br /> Authorized Signature:: ei � . <br /> = S <br /> Fees: x Total Due <br /> No. of Pages Rate per Page <br />