Free UJS Scheduled Court Records Disposal Certification Request - Pennsylvania

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.