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190435v1 <br />15 <br />Deleted: 1¶ <br />¶ <br />Exhibit 4 <br /> <br /> <br /> <br /> <br />CITY OF ARDEN HILLS <br />INFORMATION DISCLOSURE REQUEST <br />Minnesota Government Data Practices Act <br /> <br />A. Completed by Requestor <br /> <br />REQUESTOR NAME (Last, First, M.): DATE OF REQUEST: <br /> <br />STREET ADDRESS: <br /> <br />PHONE NUMBER: <br /> <br />CITY, STATE. ZIP CODE: <br /> <br />SIGNATURE: <br /> <br />DESCRIPTION OF THE INFORMATION REQUESTED: <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />B. Completed by Department <br /> <br />DEPARTMENT NAME: HANDLED BY: <br />INFORMATION CLASSIFIED AS: <br /> <br /> PUBLIC NON-PUBLIC <br /> <br /> PRIVATE PROTECTED NON-PUBLIC <br /> <br /> CONFIDENTIAL <br />ACTION: <br /> <br /> APPROVED <br /> <br /> APPROVED IN PART (explain below) <br /> <br /> DENIED (explain below) <br />REMARKS OR BASIS FOR DENIAL INCLUDING STATUTE SECTION: <br />PHOTOCOPYING CHARGES: <br /> <br /> NONE <br /> <br /> ______ Pages x ______________= ____________ <br /> <br /> Special Rate: ______________ (attach explanation) <br />IDENTITY VERIFIED FOR PRIVATE INFORMATION: <br /> <br /> IDENTIFICATION: DRIVER’S LICENSE, STATE I.D., etc. <br /> <br /> COMPARISON WITH SIGNATURE ON FILE <br /> <br /> PERSONAL KNOWLEDGE <br /> <br /> OTHER: ________________________________________ <br /> <br />AUTHORIZED SIGNATURE: DATE: