State Form 42035 (R6 / 2-01)
Return completed notice to: COMMISSION ON PUBLIC RECORDS 402 W WASHINGTON ST RM W472 INDIANAPOLIS IN 46204-2739 or e-mail to:
Type of coordinator
Forms (Forms only) Records (Records only) Information (Forms & Records)
Effective date of change
IMPORTANT NOTICE: Indiana law [IC 5-15-5.1-10 (7)] requires that an Information Coordinator be designated by each agency. Agency may prefer to designate two persons - one for Forms, one for Records.
Name and complete address of state agency
Agency number Name of previous coordinator Name of new coordinator
Division Name of agency head Signature of agency head Telephone number
Working title of new coordinator E-mail address Signature of new coordinator
Telephone number Fax number Date signed
DISTRIBUTION: White - Commission on Public Records; Canary - Agency Coordinator
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