UNIFIED JUDICIAL SYSTEM SCHEDULED COURT RECORDS DISPOSAL CERTIFICATION REQUEST [Pursuant to PA RJA 507(b)]
COUNTY JUDICIAL DISTRICT MAGISTERIAL DISTRICT
IF APPLICABLE
DISTRICT JUSTICE NAME
OFFICE OF ORIGIN
PERSON MAKING DISPOSAL REQUEST (RECORD CUSTODIAN)
ADDRESS
Approval Requested For:
RECORD TITLE AND INCLUSIVE DATES (one series per form)
Records Destruction
Records Transfer to PHMC
DESCRIPTION OF RECORD (include type of information contained and purpose of record)
RETENTION PERIOD IN SCHEDULE
PAGE AND SECTION IN SCHEDULE
HAVE ALL AUDIT REQUIREMENTS BEEN MET?
Yes
QUANTITY
No
Not Applicable
TOTAL CUBIC FEET No. of cartons No. of volumes No. of file drawers
HAVE RECORDS BEEN MICROFILMED?
Length Length Legal Yes No Other Cassette Letter
Width Width Other
Height Height
OF AVERAGE CARTON OF AVERAGE VOLUME
ARCHIVAL MEDIUM UTILIZED
Size: Form:
16mm Roll Other
35mm Cartridge
Fiche
LOCATION OF SECURITY COPY
FOR USE BY RECORD CUSTODIAN
hereby requests that the Record Retention Officer seek approval from the Administrative Office of Pennsylvania Courts for permission to dispose of or transfer the records identified above.
Date
Signature FOR USE BY DISTRICT RECORDS RETENTION OFFICER
Phone Number
Authorization to dispose of or transfer the above-identified records is requested. If destruction of the records is requested, I certify that the records have been reproduced on a medium approved by the Administrative Office of Pennsylvania Courts.
Date Signature FOR USE BY THE ADMINISTRATIVE OFFICE OF PENNSYLVANIA COURTS Judicial District
Review by the Pennsylvania Historical and Museum Commission Date Concur With Request Signature Recommend Denial of Request
is
is not
requested. Title
FOR USE BY THE PENNSYLVANIA HISTORICAL AND MUSEUM COMMISSION ONLY IF REVIEW REQUESTED BY AOPC
Recommend Disposal Request Be Amended As Follows:
Date Approval is given for: Comments/Amendments: Destruction Disapproved
Signature
FOR USE BY THE ADMINISTRATIVE OFFICE OF PENNSYLVANIA COURTS
Title
Destruction as Amended Transfer to PHMC Retain Pending Further Instructions
Date Signature Title Original must be sent to the Administrative Office of Pennsylvania Courts, 1515 Market Street, Suite 1414, Philadelphia, PA 19102. Keep a copy for your records.