Free 52408.FH11 - Indiana

MICROFORM TRANSMITTAL AND RECEIPT STATE AGENCY
State Form 52408 (10-05)

RESET FORM

Page 1 of ________ pages

INDIANA COMMISSION ON PUBLIC RECORDS / INDIANA STATE ARCHIVES

Complete form and send to: Indiana Commission on Public Records 100 North Senate Avenue, Room N055 Indianapolis, IN 46204

Telephone : 317-233-3746 Fax: 317-233-0908 Commissions Web Page: http:/www.in.gov/icpr/

Instructions and Guidelines for Transferring Microform Records 1. USE A SEPARATE FORM FOR EACH RECORD SERIES. 2. This form is to be used only for the transfer of records on any type of Microform. Microform means any type of microfilm, microfiche, or Computer Output Microfiche (COM). 3. Complete and send this form to the Indiana Commission on Public Records (ICPR) before sending the microform records. The ICPR will not accept any microform records without prior approval of this transmittal form. An approved copy of this form must accompany the microform shipment. 4. Microform records transferred to the Indiana State Archives on an approved retention schedule must have a Record Series Number. Microform records not on an approved retention schedule will be accepted or rejected on a case by case basis. 5. By signing this form, a state agency transfers ownership of the microform records to the ICPR. See IC 5-15-5.1-11. 6. Any microform record transferred to the Archives is considered to be a permanent record. The microform records must therefore meet the standards outlined in 60 IAC 2. The state agency is required to use acid free boxes. The state agency must label the boxes using State Form 36074, which can be ordered from the ICPR, Micrographics Division. 7. The state agency must verify the completeness and legibility of the records on the microform and must provide an inventory of the records on the microform.
Name of state agency Name of division of state agency

Record series title

Record series number

Total number of rolls or fiche sheets in shipment

Roll numbers

Inclusive dates of records filmed (month, day, year)

From:

To:

From:

To:

AUTHORIZATION TO TRANSFER MICROFORM RECORDS (to be filled out by the state agency or county)
Signature of records coordinator Printed name of records coordinator Date signed (month, day, year)

Address (number and street, city, state, ZIP code)

Telephone number

Fax number

E-mail address

(
Signature of person shipping microform records, if different

)

(

)

Printed name and title of person shipping microform records, if different Date signed (month, day, year)

The transfer of the microform records is

RECEIPT OF MICROFORM RECORDS (ICPR use only) Accepted Rejected. If rejected, state the reasons:

Signature of ICPR employee authorizing transfer

Printed name of ICPR employee

Date signed (month, day, year)

Signature of Archives employee receiving microform records

Printed name of Archives employee

Date signed (month, day, year)

MICROFORM TRANSMITTAL AND RECEIPT STATE AGENCY
State Form 52408 (10-05)

Page _________ of ________ pages

INDIANA COMMISSION ON PUBLIC RECORDS / INDIANA STATE ARCHIVES
Name of state agency Name of division of state agency

Record series title

Record series number

Total number of rolls or fiche sheets in shipment

Roll numbers

Inclusive dates of records filmed (month, day, year)

From:

To:

From: INVENTORY OF RECORDS

To:

Roll # or Sheet #s: Number rolls or sheets sequentially. Note duplicate or missing numbers. Media: Microfiche or COM; or 16mm, 35mm or 105mm film. Start / End: This could be dates, names, case numbers, etc. Roll # or Sheet#s Media Start End Description of Records