Request For Records Disposition Authority
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1
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LEAVE BLANI{
TO: GlENlE~Al
SIE~V!CIES ADMiL\lIS1T'~A1i"iO~,
lie
I - 10- - ~2 -/
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1 DATE RECEIVED
1.
FROM
(AGENCY
OR ESTABLISHMENT)
JL( ~
2 7
19;2-
Veterans
Administration
l'
/
----=-.=::c.::..:...---=--=---'-------------------1.
NOTIFICATION
TO AGENCY
2. MAJOR
SUBDIVISION
In accordance with the provisrons of 44
U.S.C.
3303a the disposal re-
Department
of Veterans
Benefits
quest. including amendments. IS approved except for Items that may
3. MINOR
SUBDIVISION
be stamped "disposal not approved" or "withdrawn"
In column 10.
Field Stations
4. NAME OF PERSON
WITH WHOM TO CONFER
S. TEL. EXT
Mar'orie
M. Leandri
389-3662
6. CERTIFICATE
OF AGENCY
REPRESENTATIVE
I hereby certify that I am authorized to act for this agency in matters pertaining to the disposal of the agency's records;
that the records proposed for disposal in this Request of
2
page(s) are not now needed for the business of
this agency or will not be needed after the retention periods specified,
D
A Request for immediate dlsposal.
[Xl
B Request for disposal after a specified period of time or request for permanent
retenti
C. DATE
E. TITLE
Director,
Information
& RegulationSt~j
9.
7.
8. DESCRIPTION
OF ITEM
10.
SAMPLE
OR
ITEM NO.
(With Inclusive
Dates or Retention
Periods)
ACTION
TAKEN
JOB NO.
Powers
of Attorney
Representation
and Declarations
of
1
Appointment. of Service Organization
as Claimant'
Representative
(VA Form 23-22), Appointment
of
Attorney
or Agent as Claimant's
Representative
(VA Form 2-22a), declaration
of representation,
or other proper power of attorney.
Disposition
a Current
folder.
originals.
Place in related
claims
b Obsolete
(revoked) originals.
claims
folder, mark "Revoked"
agent whose power of attorney
Remove
from
and forward
to
has been revoked.
2
Acknowledgment
of Appointment
as Claimant's
Representative
(VA Form 23-22-1,
copy 3), photo-
copies of Appointment
of Attorney
or Agent
as
Claimant's
Representative
(VA Form 2-22a),
photocopies
of declaration
of representation
or
photocopies
of proper power of attorney.
115-107
STANDARD FORM
115
Revised
April,
1975
Prescribed
by General Services
Administration
FPMR (41 CFR) 101-11.4
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