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Aug 23 99 12: 19p City of Columbia Heights 612-782-2801 p. 13 <br /> • <br /> Exhibit 3 <br /> CITY OF COLUMBIA HEIGHTS <br /> INFORMATION DISCLOSURE REQUEST <br /> Minnesota Government Data Practices Act <br /> A. Completed by Requester <br /> Requester Name (Last, First,M) Date of Request: . <br /> Street Address: Phone Number: <br /> City, State,Zip: Signature: <br /> Description of the Information Requested: <br /> B. Completed by Department <br /> Department Name: Handled by: <br /> Information Classified as: Action: <br /> Public o Non-Public o Approved <br /> o Private o Protected Non-Public a Approved in Part (Explain below) <br /> o Confidential a Denied (Explain below) <br /> Remarks or Basis for Denial including Statute Section: <br /> Photocopying Charges: Identity verified for Private Information: <br /> o None o Identification: Driver's License, State ID, etc. <br /> a Pages x ¢= o Comparison with Signature on File <br /> o Special Rate: (attach explanation) a Personal Knowledge <br /> a Other: <br /> Authorized Signature: <br />