Form 47167 - Notice To Records Coordinator - State Of Indiana
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1NOTICE TO RECORDS COORDINATOR
State Form 47167 (6-95)
Please check the enclosed SF-16(s) with appropriate agency division regarding any pending litigation or audit. If for any
reason these records may not be destroyed, check the appropriate box below and sign. Return BOTH copies of the
unsigned SF-16 to the Records Center. If records may be destroyed, sign SF-16 and send white copy to CPR / Records
Management Division, W472, Indiana Government Center South.
State audit pending
Federal audit pending
State / Federal litigation (copy of court order attached)
Other _______________________________________________
Possible destruction date (month, day, year)
Signature of Record Coordinator
Date (month, day, year)
THIS FORM MAY BE DUPLICATED.
NOTICE TO RECORDS COORDINATOR
State Form 47167 (6-95)
Please check the enclosed SF-16(s) with appropriate agency division regarding any pending litigation or audit. If for any
reason these records may not be destroyed, check the appropriate box below and sign. Return BOTH copies of the
unsigned SF-16 to the Records Center. If records may be destroyed, sign SF-16 and send white copy to CPR / Records
Management Division, W472, Indiana Government Center South.
State audit pending
Federal audit pending
State / Federal litigation (copy of court order attached)
Other _______________________________________________
Possible destruction date (month, day, year)
Signature of Record Coordinator
Date (month, day, year)
THIS FORM MAY BE DUPLICATED.
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