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Certificate of Destruction/Transfer
Report of Records Disposition
For Records on Approved Retention Schedule
AUTHORITY
Date
Date of Approved
Schedule or Manual
Agency Name
Org. Unit
Phone / E-mail
Address
City
State
Zip
Records Disposed Of
Dates Covered
Records Series
From Thru
Estimated
Volume
(Cubic Feet)
Destroyed Transferred to Archives Other
Name
Title
Signature
Date
Retain blue copy. Forward yellow copy to Records Management Division
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