Laserfiche WebLink
Exhibit 3 <br />489828v3 DTA MU125-11 <br />EXHIBIT 3 <br />INFORMATION DISCLOSURE REQUEST <br />Minnesota Government Data Practices Act <br />A. To be Completed by Requestor <br />REQUESTOR NAME (Last, First, MI): DATE OF REQUEST: <br />STREET ADDRESS: PHONE NUMBER: <br />CITY, STATE, ZIP CODE: SIGNATURE: <br />DESCRIPTION OF THE INFORMATION REQUESTED: <br />B. To be Completed by the City <br />DEPARTMENT NAME: HANDLED BY: <br />INFORMATION CLASSIFIED AS: <br />PUBLIC NONPUBLIC <br />PRIVATE PROTECTED NONPUBLIC <br />CONFIDENTIAL <br />ACTION: <br />APPROVED <br />APPROVED IN PART (explain below) <br />DENIED (explain below) <br />REMARKS OR BASIS FOR DENIAL INCLUDING STATUTE SECTION: <br />PHOTOCOPYING CHARGES: <br />NONE <br />Pages x ______________= ____________ <br />Special Rate: ______________ (attach explanation) <br />IDENTITY VERIFIED FOR PRIVATE INFORMATION: <br />IDENTIFICATION: DRIVER’S LICENSE, STATE I.D., etc. <br />COMPARISON WITH SIGNATURE ON FILE <br />PERSONAL KNOWLEDGE <br />OTHER: ________________________________________ <br />AUTHORIZED SIGNATURE: DATE: