State Form 23628 - Record Transmittal And Receipt - Records Center Of State Of Indiana

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PAGE NO.
TOTAL PAGES
YES
NO
AUDITED
RECORD TRANSMITTAL AND RECEIPT
YES
NO
OF
MICROFILMED
State Form 23628 (R6 / 6-96)
AUTHORIZATION TO TRANSFER RECORDS
INSTRUCTIONS: 1. This transmittal must be typed in order to ensure accuracy and legibility.
Signature of information coordinator
Date signed
2. Complete and send entire form to Records Center prior to intended transfer date.
3. A receipt will be given at the time the records are transferred.
4. Location information will be sent to the agency upon completion of shelving.
Name of employee transferring records
TO:
FROM:
Complete name and address of office of origin
Title
Telephone number
STATE OF INDIANA
RECORDS CENTER
Signature of Record Center employee receiving records
RECEIPT
6400 E. 30th St.
OF RECORDS
Location / address where records may be picked-up
Date
Title
Indianapolis IN 46219
Telephone: 317-591-5325
Restrictions to access
Yes
No
RECORDS DATA
TO BE COMPLETED BY RECORDS CENTER
DISPOSAL
RECORDS SERIES
CARTON
DATE
DATES
NOTES
LOCATION
ACCESSION
NUMBER
NUMBER
MO.
YR.
RANGE
ROW
SHELF
NAME
NUMBER

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