State Form 30505 - Request For Permission To Destroy Or Transfer Certain Public Records - Indiana Commission On Public Records Page 2

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Page _____ of _____
ACTION BY COMMISSION OF PUBLIC RECORDS
(To be filled out by the County Commission of Public Records)
TO: (name of government agency)
You are hereby notified that your request to destroy or otherwise dispose of the public records listed thereon was approved
by the County Commission of Public Records at a meeting held this date, subject to the following limitations or exceptions.
In the event that neither an historical society in or of the county, nor the Indiana Commission on Public Records, State Archives
Division, procures all or part of these public records within the 60 day period required by IC 5-15-6-7, these public records may be
destroyed or otherwise disposed of by authority of the County Commission of Public Records.
Signature of Chairman of County Commission of Public Records
Date signed (month, day, year)
ATTEST: Signature of Secretary
Date after which public records may be destroyed
(60 days after above date)
NOTIFICATION BY HISTORICAL SOCIETY OR
INDIANA COMMISSION ON PUBLIC RECORDS, STATE ARCHIVES DIVISION TO PROCURE RECORDS
You are further notified that:
1. No written statement has been received from any historical society or the Indiana Commission on Public
Records, State Archives Division, to procure any of such records.
2. A written statement has been received from ____________________________________________________
_______________________________________________________________________________________
of its intent to procure the following records.
Signature of Secretary
Date signed (month, day, year)

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