State Form 16 - Records Destruction Nootification
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1RECORDS DESTRUCTION NOTIFICATION
Mail To: Commission on Public Records
State Form 16 (R7 / 4-05)
402 West Washington Street Rm. W472
COMMISSION ON PUBLIC RECORDS
Indianapolis, IN 46204
INSTRUCTIONS:
1. Please type or print legibly.
2. Forward completed notification to address in the upper right corner of this form.
3. Signature must be signed by hand.
These records will be destroyed in accordance with I.C. 5-15-5.1.
Name of Agency
Name of Division
Date of Destruction (month, day, year)
Records Series Number
Date of Records (month, day, year)
Records Series Title
Location of Boxes
Method of Destruction
Courtesy Destruction
Cubic Feet Destroyed
Signature of Agency Records/Forms Coordinator
Date (month, day, year)
FOR RECORDS CENTER USE ONLY
Location
Box Number(s)
Accession Number
Destroyed By:
FOR RECORDS MANAGEMENT USE ONLY
Approved
Not Approved
Transfer to State Archives
(See attached for explanation.)
(Do not destroy.)
Signature of Records Management Staff
Date (month, day, year)
DISTRIBUTION: White - Records Management; Canary - Agency; Pink - Records Center
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