Last updated: June 19, 2018
CITY OF DULUTH
REQUEST FOR INFORMATION FORM
FOR DATA SUBJECTS
Minnesota Government Data Practices Act
GOVERNMENT DATA PRACTICES ACT CLASSIFICATION WARNING: The data you supply on this form will be used to process
your data request. The information you provide on this form is subject to the Minnesota Government Data Practices Act and
may be classified as public or private. You are not legally required to provide this data, but we may not be able to process
NAME*: _________________________________________________________________________
* To request data as a data subject, you must show a valid state ID, such as a driver’s license, military
ID, or passport, as proof of identity. You must provide proof of your identity before the City can release
the data to you. This form includes a list of acceptable forms of identification.
PHONE NUMBER: ____________________________________________________________
EMAIL ADDRESS: ____________________________________________________________
MAILING ADDRESS: ____________________________________________________________
____________________________________________________________
REQUEST DATE: ____________________________________________________________
Describe the data you are requesting as specifically as possible:
I am requesting access to data in the following way: (mark one):
Inspection – no charge
Copies –25 cents per page for 100 or fewer paper copies of letter or legal sized paper copies (2-sided is 50
cents a copy). For copies of other data (more than 100 paper copies, photographs, data on a CD or DVD,
data stored electronically, etc.) the City charges the actual cost (not to exceed $25.00 per hour for employee
time) after the first one hour of employee time per data request. The first hour of employee time per data
request is free of charge.
Both inspection and copies - see charges above. You have the right to look at data, free of charge, before
deciding to request copies.
SIGNATURE: _______________________________________________________________________
Please submit this form via email to the City Clerk’s Office, or by mail, or hand delivery: Room 330,
City Hall, 411 West First Street, Duluth, MN 55802.
Identity Confirmed As: ___________________________________________________________ on (Date:) _______________________
□ Approved
□ Approved in Part
□ Denied
Remarks or Basis for Denial Including Statute:
□ None □ ____ Pages x .25 cents = ________ □ Actual Costs: _____________________
Itemization of Actual Costs:
click to sign
signature
click to edit
![]()
