Records Disposition Document RECORDS DISPOSITION DOCUMENT NO.
Revised 04/2001 PAGE 1 OF PAGES
1. AGENCY 2. DIV]SION 3. BUREAU
4. ADDRESS (Street, City, and Zip Code) 5. CONTACT (Name and Telephone Number)
6. SUBM! i I ED BY: I hereby certify that the records to be 7. NOTICE OF TNTENTZON
disposed of are correctly represented below, that any audit
requirements for the records have been fully justified, and that The scheduled records listed in Item 8 are to be disposed of in the
further retention is not required for any litigation pending or manner checked below (specify only one):
imminent, a. Destruction b. Microfilming and Destruction
Signature Date
c. Other
Name and Title
8. LIST OF RECORD SER~ES
a. b. c. d. e. f. g.
Schedule Item Title Retention Inclusive Volume Disposition
Item No. Dates in Action and Date
Cubic Completed After
Feet Authorization
9. DTSPOSAL AUTHORIZATION Disposal for the above listed 10. DISPOSAL CERTxI:ICATE The above listed records have been
records is authorized. Any deletions or modifications are disposed of in the manner and on the date shown in column g.
indicated.
Signature Date
Name and Title
Records Custodian or Designee Date Witness
NOTE: Upon disposition retain this form for your records.