Free 47167.PDF - Indiana

NOTICE TO RECORDS COORDINATOR
State Form 47167 (6-95)

Please check the enclosed SF-16(s) with appropriate agency division regarding any pending litigation or audit. If for any reason these records may not be destroyed, check the appropriate box below and sign. Return BOTH copies of the unsigned SF-16 to the Records Center. If records may be destroyed, sign SF-16 and send white copy to CPR / Records Management Division, W472, Indiana Government Center South. State audit pending State / Federal litigation (copy of court order attached) Other _______________________________________________
Possible destruction date (month, day, year)

Federal audit pending

Signature of Record Coordinator

Date (month, day, year)

THIS FORM MAY BE DUPLICATED.

NOTICE TO RECORDS COORDINATOR
State Form 47167 (6-95)

Please check the enclosed SF-16(s) with appropriate agency division regarding any pending litigation or audit. If for any reason these records may not be destroyed, check the appropriate box below and sign. Return BOTH copies of the unsigned SF-16 to the Records Center. If records may be destroyed, sign SF-16 and send white copy to CPR / Records Management Division, W472, Indiana Government Center South. State audit pending State / Federal litigation (copy of court order attached) Other _______________________________________________
Possible destruction date (month, day, year)

Federal audit pending

Signature of Record Coordinator

Date (month, day, year)

THIS FORM MAY BE DUPLICATED.