Free 00016.FH11 - Indiana

RECORDS DESTRUCTION NOTIFICATION
State Form 16 (R7 / 4-05)

COMMISSION ON PUBLIC RECORDS INSTRUCTIONS: 1. Please type or print legibly.

Mail To: Commission on Public Records 402 West Washington Street Rm. W472 Indianapolis, IN 46204

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 Records Series Title Method of Destruction Signature of Agency Records/Forms Coordinator Cubic Feet Destroyed Name of Division Records Series Number Courtesy Destruction Date of Destruction (month, day, year) Date of Records (month, day, year) Location of Boxes Date (month, day, year)

FOR RECORDS CENTER USE ONLY
Location Accession Number Box Number(s) Destroyed By:

FOR RECORDS MANAGEMENT USE ONLY Approved
Signature of Records Management Staff

Not Approved (See attached for explanation.)

Transfer to State Archives (Do not destroy.)
Date (month, day, year)

DISTRIBUTION: White - Records Management; Canary - Agency; Pink - Records Center