4.2 ERMUSR 03-13-2018 - Laserfiche WebLink

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INFORMATION DISCLOSURE REQUEST Elk Riv* Minnesota Government Data Practices Act Municipal Utilities A. COMPLETED BY REQUESTER REQUESTER NAME(LAST, FIRST,M): DATE OF REQUEST: STREET ADDRESS: PREFERRED METHOD OF CONTACT: ❑ PHONE ❑ MAIL ❑ EMAIL 0 FAX CITY,STATE,ZIP CODE: PHONE NUMBER: SIGNATURE: FAX NUMBER: EMAIL: Note:Elk River MunicipalUtilities cannot require you,as a member of the public,to identi)yourself or explain the reason foryour data request.However,depending on how you want us to process your request,we may need some information aboutyou.Please keep in mind that if we do not understandyour request and have no way to contactyou,we will not be able to begin processing your request. DESCRIPTION OF THE INFORMATION REQUESTED-please describe the data you are requesting as specifically as possible.If you need more space,please use the back of this form or attach additional sheets: B. COMPLETED BY DEPARTMENT DEPARTMENT NAME: HANDLED BY: INFORMATION CLASSIFIED AS: ACTION: ❑Public 0 Non-Public 0 Approved 0 Approved in Part(explain below) ❑Private 0 Protected Non-Public 0 Denied(explain—include statute) 0 Confidential REMARKS OR BASIS FOR DENIAL,INCLUDING STATE STATUTE: Note:According to MS ff 13.03,subd.3,authorities us to charge fees to recover costs to provide copies of data,including costs associated with searching,compiling,copying,mailing,or otherwise transmitting data.Prepayment is required prior to receiving copies of data.We do not charge for inspection of data or for separating not public data from public data. COPY CHARGES: IDENTITY VERIFIED FOR PRIVATE INFORMATION: ❑ None 0 Identification:Driver's License,State ID,Etc. O Pages x.25¢ per page(per side) =$ 0 Comparison with Signature on File ❑ Employee Time(only charge if over 100 pg) =$ 0 Personal Knowledge (15 min minimum) 0 Other: O Other Charges: =$ O Special Rate: (attach explanation) =$ Total Charges: $ AUTHORIZED SIGNATURE: DATE: 6