Free 23628 Proof.FH11 - Indiana

RECORD TRANSMITTAL AND RECEIPT
State Form 23628 (R8 / 6-06)

Reset Form

AUDITED MICROFILMED

YES YES

NO NO

PAGE NO.

TOTAL PAGES OF

INSTRUCTIONS: 1. 2. 3. 4.

This transmittal must be typed in order to ensure accuracy and legibility. Complete and send entire form to Records Center prior to intended transfer date. A receipt will be given at the time the records are transferred. Location information will be sent to the agency upon completion of shelving. TO FROM
Complete name and address of office of origin

AUTHORIZATION TO TRANSFER RECORDS
Signature of information coordinator Name of employee transferring records Title T elephone number Date signed (month, day, year)

STATE OF INDIANA RECORDS CENTER 6400 E. 30th St. Indianapolis IN 46219 T elephone: 317-591-5325

RECEIPT OF RECORDS
Signature of Record Center employee receiving records Location / address where records may be picked-up Title Restrictions to access Date signed (month, day, year)

Yes

No
TO BE COMPLETED BY RECORDS CENTER ACCESSION NUMBER LOCATION RANGE ROW SHELF

RECORDS DATA
RECORDS SERIES NAME NUMBER DISPOSAL DATE
MONTH YEAR

DATES

NOTES

CARTON NUMBER

DISTRIBUTION:

White - Records Center; Canary - Return to agency with location information; Pink - Records Center; Goldenrod - Return to agency