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� OR0210 ADIriTNIS�RATIVE OFFI�S <br /> 2NFORMATION DISCLOSIIRE RE4IIEST <br /> 2iZNNESOTA Ga DATA P��CTSCES ACT <br /> ' gEQIIESTER Na�E: . <br /> A. Request Frequenc� - Private Data on individuals. A�te�' Y°u <br /> have been supplied the data and infor�ed of its meaning, the <br /> data need not be disclosed to you �or six montns thereafter <br /> unless a dispute or ac�ion is pendiag or additional data -on <br /> you .has been collected. <br /> B, you may be reauired to pay actua? costs in making, <br /> certif ying and%or com�iling the copies oi inLOr�zt1On <br /> requested. � <br /> Date of Request: � � � / <br /> ` � , �' � - <br /> Requester Name= <br /> citY: �-� ' <br /> Address: <br /> Zip- ��_�% / <br /> �'S `-���— Busines C�j D�� - <br /> gome Phone: � ._ , <br /> ested: ' � <br /> Description of Information Requ ^ � <br /> , . <br /> � ' / <br /> �!�': <br /> Recraester'. s Signature: �� � <br /> BgyOW II7gOF2MATIQN TO BE FI?�L IN BY DEPARTMENT ONLY <br /> Handled By: <br /> Department= <br /> Request Type: _In Persan . <br /> Mail Phone <br /> Subjec= of Data Not Subje�� or Datz <br /> gequested By= ` <br /> Inf ormation Requ <br /> ested is Classified: ?u�I.i� Private <br /> Confidential Non-�ublic �rotected Non-Public <br /> Aporoved Denied Approved in_Part <br /> gequest is: _ — <br /> Remarks/Comments. <br /> ...___..__ <br /> _ G 2 <br /> Authorized Signatur�: <br /> _ $ <br /> Fees:� X Total Due .. <br /> No. of Pages Rate per Page <br />