10.01 - Data Practices Policies - Laserfiche WebLink

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Data Request Form A. To be Completed by Requester(optional for the sole purpose of facilitating access to data) Requester Name(Last,First,M.): Phone Number: Street Address: Fax Number: City,State,Zip Code: Email Address: Signature: Date of Request: Note: According to MS§13.05,subd. 12,persons are not required to ident'themselves,or state a reason for,or juste a request for public data. I am requesting access to data in the following way: ❑Inspection ❑Copies ❑Both inspection and copies Note: Minn.Stat.§13.03 and 13.04 authorize the City to charge fees to recover costs to provide copies of data.Prepayment is required.There is no charge for inspection or for separating not public data from public data. The City may charge the actual cost for searching and retrieving data,except for requests made by data subjects. Note:The City will respond within a reasonable time for all requests,except for requests by data subjects,which shall be responded to within 10 days of the date of the request. Description of the Information Requested(attach additional pages if needed): B. To be Completed by City Department Department Name: Handled by: Information Classified as: Action: ❑ Public ❑ Non-Public ❑ Approved ❑ Private ❑ Protected Non-Public ❑ Approved in Part(Explain below) ❑ Confidential ❑ Denied(Explain below) Remarks or basis for denial including statute section: Copying Charges: Proof of Identity Verified of Requester of Private Data as the ❑ None Data Subject: El Members of the Public(100 or fewer copies): ❑ Valid Identification:Driver's License,State ID, Military ID,Passport,Etc. Pages x$.25 per Black/White Page = ❑ Comparison with Signature on File Pages x$.50 per Color Page = ❑ Personal Knowledge ❑ Members of the Public(more than 100 copies)and Data subjects: ❑ Other: Employee time:$ /hr x Hours = Pages x$ per Black/White Page = ❑ Other Charges(e.g.postage): _ Total Charges = Authorized Signature: Date: Policy required by Minnesota Statutes,section 13.025,subdivision 2. Page 6