State Form 30505 - Request For Permission To Destroy Or Transfer Certain Public Records - Indiana Commission On Public Records

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Page _____ of _____
REQUEST FOR PERMISSION TO DESTROY OR
TRANSFER CERTAIN PUBLIC RECORDS (PR-1)
State Form 30505 (R3 / 10-03)
INSTRUCTIONS:
1. Prepare in quintuplicate (five copies).
.
2.
The original and three copies shall be filed with the County Commission of Public Records and a copy retained by the
originating agency.
3.
Upon approval by the County Commission, the Secretary shall forward one copy to the Indiana Commission on Public
Records, 402 W Washington St., Rm W472, Indianapolis, IN 46204; one copy to the county historical society (if any);
and retain the original and one copy for 60 days, during which time the records may be procured by an active historical
society of the county or by the Indiana Commission on Public Records, State Archives Division.
4.
Upon the expiration of 60 days the copy retained shall be forwarded to the agency, as authority to dispose of the records
in accordance with the action thereon by the County Commission.
5.
The original shall be preserved as a part of the minutes of the County Commission.
TO BE FILLED OUT BY ORIGINATING AGENCY OR OFFICE
Government agency
Date (month, day, year)
Address of government agency
Check proper box below:
Request to destroy
Request to destroy previously microfilmed originals
Request to microfilm and destroy
Request to transfer to:
RECORDS MEASUREMENT TABLE
TO: Secretary, Commission of Public Records, of
1 Archives box (10" X 12" X 15" inside) = 1 cu. ft. of records
1 Letter size file drawer = 1 1/2 cu. ft. of records
_____________________________________ County, Indiana
1 Legal size file drawer = 2 cu. ft. of records
1 Number 11 record transfer box (12" X 24" X 10!/2") = 2 cu. ft. of records
VOLUME OF RECORDS
NAME OR DESCRIPTION OF RECORD
DATE OF RECORDS
(see records measurement table)
All of the above records are more than three years old as of January 1, of the present year. All records requiring audit have been
audited by the State Board of Accounts for the period indicated; the report of the audit is on file and does not show any exceptions
taken or unsettled charges.
Approved by:
Requested by:
Title
Signature / title

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