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Submit to: <br />Data Request Form <br />City of Lino Lakes <br />600 Town Center Parkway <br />Lino Lakes, MN 55014 <br />A. To be Completed by Requester <br />Requester Name (Last, First, M.): <br />Phone Number: <br />Street Address: <br />Fax Number: <br />City, State, Zip Code: <br />Email Address: <br />Signature: <br />Date of Request: <br />Note: According to MS § 13.05, subd. 12, persons are not required to identify themselves, or state a reason for, or justify <br />a request for public data. <br />Description of the Information Requested: <br />• Confidential <br />• Denied (Explain below) <br />Remarks or basis for denial including statute section: <br />B. To be Completed by City Department <br />Department Name: <br />Handled by: <br />Information Classified as: <br />Action: <br />❑ Approved <br />❑ Public • Non - Public <br />• Private • Protected Non - Public <br />• Approved in Part (Explain below) <br />• Confidential <br />• Denied (Explain below) <br />Remarks or basis for denial including statute section: <br />Note: According to MS § 13.03, subd. 3, authorizes us to charge fees to recover costs to provide copies of data, <br />including costs associated with searching, compiling, copying, mailing, or otherwise transmitting data. Prepayment is <br />required prior to receiving copies of data. We do not charge for inspection of data or for separating not public data from <br />public data. <br />Identity Verified for Private Information: <br />Copy Charges: • None (10 pages or less) <br />❑ Over 10 pages - Pages x .25¢ per page = <br />• Identification: Driver's License, State Id, Etc. <br />• Comparison with Signature on File <br />• Over 100 pages (electronic or paper) <br />or over 1.5 hours for search and retrieval <br />Employee Time Hours = <br />• Personal Knowledge <br />• Other: <br />• Other Charges = <br />• Special Rate: (attach explanation) = <br />Total Charges: $ <br />Authorized Signature: Date: <br />