Form Ss Arc 940 - Records Officer Designation printable pdf download

RECORDS OFFICER DESIGNATION FORM

SS ARC 940 (R 3/13)

STATE OF LOUISIANA

SECRETARY OF STATE

DIVISION OF ARCHIVES, RECORDS MANAGEMENT, AND HISTORY

BATON ROUGE, LOUISIANA

For Archives Use Only

Date Received: ________________

TO:

Records Management Section

Division of Archives Records Management and History

Updated: _____________________

P.O. Box 94125, Capitol Station

Baton Rouge, LA 70804-9125

Updated by: __________________

FAX (225) 922-1220

Instructions: In compliance with LAS-R.S. 44:411, on or before July 1 of each state fiscal year, the chief executive

officer of each agency shall designate a records officer to act as liaison between the Division of Archives, Records

Management and History and the agency on all matters related to records management and communicate that designation

by completing this form, in its entirety and submit it to the State Archives. If returned after January 1st in a year where a

designation has not been made, the designation will cover the balance of the remaining fiscal year and the upcoming fiscal

year the form for which the form being submitted. Please complete and return by fax or mail to the address or fax

number listed above.

PLEASE PRINT CLEARLY ALL INFORMATION REQUESTED BELOW.

1. Agency: _____________________________________________________________________________

2. Agency Mailing Address: _______________________________________________________________

3. Agency Chief Executive: _______________________________________________________________

4. Executive’s Title: _____________________________________________________________________

5. Executive’s E-mail Address: ___________________________@______________________________

6. Exec Phone Number: (_____) _______- ________ 7. Exec Fax Number: (_____) _______ - __________

8. Date Executive Appointed or Elected to current position: ___________________

9. Date Executive’s current term ends:____________ (date of next election or N/A if not applicable).

10. Agency Records Designee: _______________________________________________________________

11. Designee’s Title: _____________________________________________________________________

12. Designee’s E-mail Address: ___________________________@______________________________

13. Des Phone Number: (_____) _______- ________ 14. Des Fax Number: (_____) _______ - __________

As Chief Executive Officer of the agency listed above, I hereby designate the person listed above for the State Fiscal Year

beginning July 1, 20___ and ending June 30, 20____.

In the event that our designee changes during the year indicated above,

we will notify your office of the change and our new designee within thirty days of any such change.

Executive Signature:_________________________________________________________________

Executive Title: ___________________________________Date: _____________________________

Form Ss Arc 940 - Records Officer Designation