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CITY OF ELK RIVER <br />INFORMATION DISCLOSURE REQUEST <br />Minnesota Goverment Data Practices Act <br />A. REQUESTER COMPLETE <br />Note: Request Frequency - Private Data on individuals. After you have been shown the data and informed of its meaning, the data need not be disclosed to you <br />six months thereafter unless a dispute or action is pending or additional data on you has been collected. <br />You may be required to pay the actual costs of making, certifying and/or compiling the copies of information requested. <br />1. REQUESTER NAME (Last, First, MI) <br />2. DATE OF REQUEST <br />3. ADDRESS (it needed) <br />4. PHONE (if neoded) <br />5. DESCRIPTION OF THE INFORMATION REQUESTED <br />6,. REQUESTER SIGNATURE <br />L <br />44 JWW AAc J"Ullc UUL UU ALUL IJIVYAJJc r.;UjLipicLc: uumajauun on numDers L ix,4 apevc, me aam may not De Me 10 De reteaSeC 10 You. <br />P111111111 I I <br />7. DEPARTMENTIDIVISION NAME <br />8. REQUEST HANDLED BY <br />9. REQUEST TYPE <br />10. REQUESTED BY <br />El In -Person ❑ mail El Phone <br />❑ Subject or Data D Not the Sukiect of Data <br />11. THE INFORMATION REQUESTED IS CLASSIFIED: <br />1) Public El Nom -Public El Private 0 Protected Non -Public ❑ Confidential <br />12. REQUEST <br />13, AUTHORIZED SIGNATURE <br />n Approved D Denied 13 Approved in Part (Explain in#14) <br />Today's Date <br />14. REMARKS/COMMENTS (If requested data is classified so as to deny access to the requester cite authority or reason. Also enter any other remarks or comments that arc <br />appropriate.) <br />C. DEPARTMENT/DIVISION COMPLETE WHEN FEES ARE ASSESSED (A receipted copy of this form <br />is to be provided to the requester each time money is received) <br />15. El Fees: Flat Rate Fees Special Rate <br />—(No. —of Pgs) X (Cost/Page) 16. El <br />I have received from the above named, the amount indicated opposite my signature in payment for providing the <br />information requested. <br />D. REQUESTER PLEASE NOTE ITEMS CHECKED <br />1. 0 Make checkJmoney order payable to The City of Elk River <br />2. D If mailed, return entire form and any fees to: <br />Received BY <br />Today's Date <br />17. Total Amount Due <br />S <br />Received By <br />Today's Date <br />I 8a. Amount to be prepaid <br />5 <br />(50% of est, totals over $50.00) <br />Received By <br />Today's Date <br />18b. Balance Due <br />(Upon completion of copying) <br />D. REQUESTER PLEASE NOTE ITEMS CHECKED <br />1. 0 Make checkJmoney order payable to The City of Elk River <br />2. D If mailed, return entire form and any fees to: <br />