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Page 14 of 21 <br />Address: <br />Phone number: <br />Email address: <br />You do not have to provide any of the above contact information. However, if you want us <br />to mail you copies of data, we will need some type of contact information. In addition, if we <br />do not understand your request and need to get clarification from you, without contact <br />information we will not be able to begin processing your request until you contact us. <br />City of Lake Elmo <br />Data Request Form - Data Subjects Date of request: <br />To request data as a data subject, you must show a valid state ID, such as a driver's license, <br />military ID, or passport as proof of identity. <br />I am requesting access to data in the following way: <br />❑ Inspection ❑Copies ❑ Inspection and copies <br />Note: inspection is free, for copies we charge $0.25 per page for up to 100 pages ($0.50 two <br />sided up to 50 pages) or employee time, the cost of the materials onto which we are copying <br />the data (paper, CD, DVD, etc.), and mailing costs (if any). If your request is for copies of data <br />that we cannot reproduce ourselves, such as photographs, we will charge you the actual cost <br />we must pay an outside vendor for the copies. The cost of employee time to make copies is <br />calculated at the actual hourly rate of the employee. <br />Description of data requested: <br />Note: Describe the data you are requesting as specifically as possible. If you need more <br />space, please use the back of this form. <br />Contact Information <br />