Free 30505.FH11 - Indiana

REQUEST FOR PERMISSION TO DESTROY OR TRANSFER CERTAIN PUBLIC RECORDS (PR-1)
State Form 30505 (R3 / 10-03)

Page _____ of _____

INSTRUCTIONS:

1. Prepare in quintuplicate (five copies). . 2. The original and three copies shall be filed with the County Commission of Public Records and a copy retained by the originating agency. 3. Upon approval by the County Commission, the Secretary shall forward one copy to the Indiana Commission on Public Records, 402 W Washington St., Rm W472, Indianapolis, IN 46204; one copy to the county historical society (if any); and retain the original and one copy for 60 days, during which time the records may be procured by an active historical society of the county or by the Indiana Commission on Public Records, State Archives Division. 4. Upon the expiration of 60 days the copy retained shall be forwarded to the agency, as authority to dispose of the records in accordance with the action thereon by the County Commission. 5. The original shall be preserved as a part of the minutes of the County Commission. TO BE FILLED OUT BY ORIGINATING AGENCY OR OFFICE
Date (month, day, year)

Government agency Address of government agency

Check proper box below:

Request to destroy Request to destroy previously microfilmed originals Request to microfilm and destroy Request to transfer to:
RECORDS MEASUREMENT TABLE 1 1 1 1 Archives box (10" X 12" X 15" inside) = 1 cu. ft. of records Letter size file drawer = 1 1/2 cu. ft. of records Legal size file drawer = 2 cu. ft. of records Number 11 record transfer box (12" X 24" X 10!/2") = 2 cu. ft. of records DATE OF RECORDS

TO: Secretary, Commission of Public Records, of _____________________________________ County, Indiana
NAME OR DESCRIPTION OF RECORD

VOLUME OF RECORDS (see records measurement table)

All of the above records are more than three years old as of January 1, of the present year. All records requiring audit have been audited by the State Board of Accounts for the period indicated; the report of the audit is on file and does not show any exceptions taken or unsettled charges.
Approved by: Title Requested by: Signature / title

Page _____ of _____ ACTION BY COMMISSION OF PUBLIC RECORDS (To be filled out by the County Commission of Public Records)
TO: (name of government agency)

You are hereby notified that your request to destroy or otherwise dispose of the public records listed thereon was approved by the County Commission of Public Records at a meeting held this date, subject to the following limitations or exceptions.

In the event that neither an historical society in or of the county, nor the Indiana Commission on Public Records, State Archives Division, procures all or part of these public records within the 60 day period required by IC 5-15-6-7, these public records may be destroyed or otherwise disposed of by authority of the County Commission of Public Records.
Signature of Chairman of County Commission of Public Records ATTEST: Signature of Secretary Date signed (month, day, year) Date after which public records may be destroyed (60 days after above date)

NOTIFICATION BY HISTORICAL SOCIETY OR INDIANA COMMISSION ON PUBLIC RECORDS, STATE ARCHIVES DIVISION TO PROCURE RECORDS

You are further notified that: 1. No written statement has been received from any historical society or the Indiana Commission on Public Records, State Archives Division, to procure any of such records. 2. A written statement has been received from ____________________________________________________ _______________________________________________________________________________________ of its intent to procure the following records.

Signature of Secretary

Date signed (month, day, year)