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Elk River : INFORMATION DISCLOSURE REQUEST Municipal Utilities Minnesota Government Data Practices Act 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 Municipal Utilities cannot require you,as a member of the public,to identii yourself or explain the reason foryour data request.However,depending on how you want us to process your request,we may need some information about you.Please keep in mind that if we do not understand your request and have no way to contact you,we will not be able to begin processingyaur 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 ❑ Approved 0 Approved in Part(explain below) ❑Private ❑Protected Non-Public 0 Denied(explain—include statute) ❑Confidential REMARKS OR BASIS FOR DENIAL,INCLUDING STATE STATUTE: Note:According to MS c 13.03,subd.3,authorizes 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. ❑ Pages x.25¢ per page(per side) =$ 0 Comparison with Signature on File Cl Employee Time(only charge if over 100 pg) _$ 0 Personal Knowledge (15 min minimum) 0 Other: O Other Charges: =S ❑ Special Rate: (attach explanation) =S Total Charges: $ AUTHORIZED SIGNATURE: DATE: 8