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OROPIO ADMINIS�RATIVE OFFI�S <br /> INFORMATION DISCI�OSTTRE REQIIEST <br /> MINNESOTA Ga DATA PR�CTICES ACT <br /> ' gEQDESTF.R NOTE: <br /> A, Request Freauency - Private Data on individuals. After you <br /> have been supp lied the data and inf ormed of its meaning, <br /> the <br /> data need not be disclosed to yendinq or additional edatat�on <br /> unless a dispute or ac�ion is p <br /> you has been collected. <br /> B , you may be required to pay actual costs in making, <br /> certifying and/or comailing the copies oz inforazation <br /> requested. - <br /> I � ��.- q�' <br /> Date of Request: <br /> . . 1 {/, <br /> Requester Name: <br /> Address: (p �O .°I.�p L-�Q. City: v <br /> Z ip: � J ��O �'" <br /> gome Phones <br /> [,� � �-.- L..� -�,- ,�j � Business: <br /> ���i�'��� �. �-�^.-.r.a.d <br /> Description of Information R ested: P� � � <br /> � <br /> �_ <br /> ��' .... �^_�, <br /> Requester' s Signature: <br /> BELOW INFORM�TION TO BE FILLED IN BY DEPARTMF?t7T ONLY <br /> � � 2 Eanaled By: -'� - <br /> Department: <br /> In erson Mai1. Phone <br /> gequest Type: _� P <br /> gequested By: Subjec� o= Data <br /> p< Not Sub j ect of Data <br /> Information Re�quested is Classified: 0� <br /> �ublic Private <br /> Confidential Non-�ublic =rotected Non-Publ.ic <br /> gequest is: <br /> �pproved Denied Anproved in Part <br /> Remarks/Co�ents_ <br /> Authorized Signature" <br /> _ $ <br /> Fees:� x Total Due <br /> No. of Pages Rate per Page <br />