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ORONO ADMSNISZ`RATSVE OFF2�S � <br /> �TEORMATION DISCLOnS�UREPR 4�I�S gCT <br /> � i42NNESOTA Ga , <br /> • gEQUES�F•�Z NO�E: . <br /> A, gequest Frequency - Private Data on iadividual.s. �'�te- �°ho <br /> have been supoZied the data and ouf foresixf monu�se hereafter � <br /> data need not be disclosed to yendinq vr adaitional data -on <br /> .unless .`a dispute or ac�ion is �p <br /> you .has been col.lected. <br /> B, you may be reauired to pay �actual cos�s in �aking. <br /> certifying and/or co��iling the copies or in=oraati°r <br /> requested. • <br /> /.Z'� _� � <br /> Date of Request: <br /> r ' A <br /> /G <br /> Requester Namez /� <br /> City: �/�`�'��� <br /> p�r3dress: �� <br /> Zip: � <br /> H�e Phone: <br /> �� `� --�' � l/ Busines s: <br /> Descrip'tion of 2nformation Reuueste3: � _ <br /> ���t^�% <br /> l�j�` <br /> Retruester'. s Signature: <br /> Bg1,OW =NgORMATION TO BE FII�LE� IN BY DEPAR�N� OKLY <br /> Handled. By: <br /> D ep art�'ue.at= <br /> Mai�. Phone <br /> gequest TypeS _Yn pe="san . — -- <br /> g�quested By= _ <br /> Subjec� vf Data Not Sub�ect or Data <br /> �fo�a�on gequeste3 is Classified: <br /> �unlic _Private <br /> Conf idential <br /> Non-�ublic =rotected Non-Public <br /> — pnproved in Part <br /> Aporoved Denied -- - � <br /> geQuest is: _ — <br /> Resaarks/Ca�m.ents- <br /> . <br /> Anthorized Signat�'e: <br /> _ $ <br /> Fees:- X Total Due .. <br /> No. of Pages Rate per Page <br />