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r �` <br /> OROLIO ADMINISTF�TZVE ��S�S <br /> rNFORMATION DISCI�OSI7RE RE4�ST <br /> IS.INNESOT� GO DATA PRACTSCES ACT . <br /> REQIIESTER N��= on individual.s. �f t�- Y°u � <br /> A, Request Frecruency - Private Data � tne <br /> have been supolied,the osed to youffo esixfm°ntnsethereafter <br /> data need not be d_sc1}, e��ing or additional data -on <br /> unless a dispute or ac�_on is p <br /> you has been coZlected. � �c�L� ? costs in making, <br /> g , You may be requ'-'-"Pd to p�- �. iniormation <br /> certifying and/or compiling �.r.e copies oz <br /> requested. � <br /> Date of Re�u <br /> est s ��'3/�� <br /> � � <br /> Requester N�e= O/w�> <br /> S�� L�c�� /�i� �'-ty: <br /> p,ddress: � <br /> Zip: <br /> Business: <br /> gome Phone: <br /> � �S <br /> Description of Informati°n Reuuested: <br /> � <br /> Re�ester' s Signature= <br /> BgyOW INgORMATION TO BE FII.L�D IN B DEPARTM�NT ONLY <br /> Handle3 By= <br /> Department= <br /> _n persan <br /> Mai? Phone <br /> Ftequest T��pe: — <br /> Not Subject of Data <br /> Subjec� or Data — <br /> Re�uested By= — , <br /> _�Z�� pr�vate <br /> Information Requested is Classified= <br /> Nor.-�,sb l;.c <br /> =rotected Nan-Punlic <br /> Conf idential <br /> geq-uest is: Aporoved <br /> Denied Approved in Part <br /> Remarks/Ca��ts: <br /> Authorize3 Signatzire: <br /> _ $ <br /> X Total Due <br /> Fees: eS Rate per Yage •: <br /> No. o= Pag <br />