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Data Request Form <br /> E1. To be Completed by Requester�opc�on�for cne So�e Pu�ose off��u�ng�ess to a�> <br /> Requester Name(Last,Firs�M.): Phone Number: <br /> Street Address: Fax Number: <br /> il <br /> City,State,Zip Code: Email Address: i <br /> Signature: Date of Request: I <br /> Note: According to MS§13.05,subd 12,persons are not required to ident�themselves,or state a reason for,or justify a � <br /> requestfor public data. <br /> I am requesting access to data in the following way: '� <br /> ❑InspecNon ❑Copies ❑Both inspecGon and copies � <br /> Note: Mittn.Stat.§13.03 and 13.04 authorize the City to charge fees to recover costs to provide copres of data. <br /> Prepayment is required There is no charge for inspection or for separaHng not public data from public data.The City may <br /> charge the aetual eost for searehing and retrreving data,exeept for requests made by data subjects. <br /> Note:The City will respond within a reasonable Nme for all requests,e�ept for requests Iry data subjects,which shall be <br /> responded to within 10 days of the date of the reguest. <br /> Description of the Information Requested(attach additional pages if needed): <br /> B. To be Completed by City Department II <br /> Department Name: Handled by: <br /> Information Classified as: Action: <br /> ❑ Public ❑ Non-Public ❑ Approved <br /> ❑ Private ❑ Protected Non-Public ❑ Approved in Part(Explain below) <br /> ❑ Confidential ❑ Denied(Eacplain below) <br /> Remarks or basis for denial including statute section: <br /> Copying Charges: Proof of Identity Verified of Requester of Private Data as the <br /> ❑ None Data Subject: <br /> ❑ Members of the Public(100 or fewer copies): ❑ Valid Identification:Driver's License,State ID, <br /> Military ID,Passport,Etc. <br /> Pages x$.25 per Black/White Page = <br /> ❑ Comparison with Signature on File <br /> Pages x$.50 per Color Page = ❑ Personal Knowledge <br /> ❑ Members of the Public(more than 100 copies)and Data subjects: ❑ Other: <br /> Employee time:$ /hr x_Hours = <br /> Pages x$_per Black/White Page = <br /> ❑ Other Charges(e.g.postage): _ <br /> Total Chazges = <br /> Authorized Signature: Date: <br /> Policy required by Minnesota Statutes,section 13.025,subdivision 2. Page 6 <br />