Free 36040.FH11 - Indiana

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REQUEST FOR APPROVAL OF NEW / REVISED FORM
State Form 36040 (R9 / 6-08)

PART ONE
Name of agency forms coordinator

AGENCY INFORMATION
Initial T elephone number Date submitted (month, day, year) Delivery requested (month, day, year) T elephone number

Name and address of agency (room number, street, city, ZIP code) Agency number Name of requester Initial

NEW FORMS - Attach a proposed version. REVISIONS - Attach a copy of the latest revision with all changes noted in red ink. Agency Forms Coordinator must initial this form signifying review and approval. PART TWO
Approval requested for:

FORM INFORMATION
Form title (If a new form, provide suggested title.) State form number

New form Revised State form

Artwork to be provided by:

Estimated annual usage

ICPR Forms Design
Size

Agency (attach or e-mail electronic copy)
Number of pages / sheets / plies

Vendor
Is this form used with a window envelope?

How is form completed?

Hand
Does the form involve the accounting of money? If yes, has this form been submitted for:

Typewriter

Electronically

Yes

No

Yes

No State employees Non-fillable PDF

State Board of Accounts approval

Auditor of State approval

If yes, send ICPR copies of both the approval memo and the approved form.

An electronic copy of this form will be placed on the State Forms Catalog. Who should have access to this form? Who will complete this form?

General public Fillable PDF Yes Yes Yes Yes Yes No No

Restricted access / other (please specify) ______________________________________________ Word
If Yes, is it:

In what format should this file be stored?

Excel

Other ____________________________________________________
Applicable State / federal statute(s)

Are you asking for Social Security number? Are you asking for confidential information? Will any other agency use this form?

Voluntary

Mandatory

If Yes, under what State / federal statute or promulgated rule is this covered? If Yes, what agency? If Yes, list title(s) and state form numbers. Is any information printed on this form by a line printer? If Yes, please attach specifics.

No No No Yes No

Is any data copied onto / from other forms? Is the record microfilmed?

Is form part of an existing record series? (for Retention Schedule) If Yes, what is the series number / title?

Yes No PART THREE
Form construction: Single flat sheet Booklets / Bond set
No.

If this form will be produced by a printing vendor, please provide the following information:
Unit set (carbonless or carbon) Envelope w/ window F = Front B = Back F F F F F F B B B Tags / Label Receipt Continuous Self-mailer Ledger Check / Warrant Other:_________________________________ Type of paper (if known)

PLY SEQUENCE COLOR DISTRIBUTION

COPY

Will the form be padded?

If yes, number of sheets per pad

Will the form be carbonless?

Yes Yes Yes Yes

No
If yes, type of perforation

Yes Horizontal
Numbered on:

No Blue impression

1 2 3 4 5 6 Comments:

B Will the form be perforated?

Will the form have carbon paper interleaves?

No No No

Vertical All plies 5 hole Post hole

Black impression
Beginning number

B Will the form be numbered?

Top ply 3 hole

B Will the form have holes punched? If yes, type of holes (send sample)

Acco type

Other _____________

PART FOUR
This request for a: form is:

FOR INDIANA COMMISSION ON PUBLIC RECORDS USE ONLY Revised Approved Conditionally approved
Name of evaluator

New

Denied
Evaluator's telephone number Date of evaluation (month, day, year)

Name of person from agency supplying information Comments:

DISTRIBUTION: Original - Forms Management; Copy - Requesting agency; Copy - Agency Coordinator