Free rcdsdisplog - Pennsylvania

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Unified Judicial System Disposal Log ­ Non-Permanent Records
1. ____________________________________
County

2. __________________________________________
Judicial District

3. ________________________________________
Record Custodian

4. ____________________________________
Office/Department

5. __________________________________________
Address

6. _________________________________________
Telephone No.

7.

8. AUTHORIZATION FOR DISPOSAL SCHEDULE [§ Name (e.g. 5.7 Juvenile)]

9.

10.

11. MICROFILMED (Y-N)

12.

RECORD TITLE

INCLUSIVE DATES OF RECORDS

FORMAT

ORIGINAL (Y-N)

FOR USE BY RECORD CUSTODIAN
I, _____________________________________________, hereby request that the Record Retention Officer authorize the disposal of the listed records. Record Custodian's Name ______________________________________________ Record Custodian's Signature ___________________________________________ Title ____________________________________ Date

FOR USE BY RECORD RETENTION OFFICER
I, _____________________________________________, hereby approve of the disposal of the records listed as requested. Record Retention Officer's Name ______________________________________________ Record Retention Officer's Signature ___________________________________________ Title ____________________________________ Date

Original to be retained by the District Record Retention Officer. Copy to be provided to the Record Custodian. Copy to be provided to the AOPC on or before January 15th each year. AOPC 507B