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. . --- <br /> OROIIO ADMINIS�R.ATSYE OFFSCES • <br /> 2NF'ORMATION DISGLO�S��PR�I�S gCT <br /> • � ISSNNESOTA GO , <br /> • gEQUES��R NOZ`E= ` • . ' <br /> • - Private� Data oa individuals. Afte'-" Yau <br /> A. gequest Frequenc� <br /> t e <br /> have been supplied the data and uf fQ es�°fmontase�eafter • <br /> data need not be disclosed ta 1'eadinc or additional data -on <br /> � � .unless :�a dispute or ac�ion is -p . � . � <br /> �� you .has� been collected. . � � <br /> you may be reauirea to •pay��actua�lies�sor in orm tian <br /> B. the co_ . <br /> certifying and/or com�iling <br /> requested. O <br /> est: 3 5 ' V ' <br /> Date of Requ � <br /> . . G. _ -- � <br /> Requester Name: �fp � • <br /> . City: � ���t b i <br /> p,.8dress: <br /> . Zip: ��`��-.�r � . <br /> Ha,me Phone z (��15�� <br /> � _ Business: ��i��l ��1 -��Uy <br /> Descrip <br /> tion of Inf ormation Rea_'uested:. t��-v <br /> � i . <br /> � gecruester'.s Signature: <br /> BgyOW INgOF�iATION TO BE FIIaLID IN BY DEPAR2�.'NT O�IT'Y <br /> Haadled BYs <br /> Departmen't= <br /> Mail Phone <br /> gequest Type= - 2n person . — — <br /> geques�ed By= Subjec:. of Data <br /> Not Subjec� of Data <br /> Pu,blic Private <br /> �fo�cation Reqaested is Classified: __ --' <br /> Non-?ublic ,__�r�tected Non-Public <br /> Confidential _ , . � ' _n Part <br /> Deniea � A�proved __ � <br /> gequest is: Agoroved — -- � � <br /> Remarks/Co�e�ts: . <br /> Anthorized Signature: • <br /> = S <br /> Fees:• X Total Due ,. <br /> Na. af Pages Rate per Page . <br />