Item #11F (Attachment: Records Management Forms) jai,,, '
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SUBMISSION OF RECORDS TO RECORDS MANAGEMENT DEPARTMENT WORKSHEET
To be completed when requesting Pick-up of records by RMD
Request date:
Pickup Requested By:
(Name and title) (Department)
Location of Pickup:
Number of Boxes: (one legal size 36" box= 2.5 cu. Ft.)
Complete description of contents to aid in matching to State of Florida retention schedules: (Include Court type, if
applicable, ie.Jury, Small Claims,Traffic, Circuit Civil, Misdemeanor,etc.)
Record Dates or Year(s)
Retention Schedule, Item Number and Title, if known (RMD personnel can help you, if needed)
Retention Period (if known) ie. 6 months, 1 year, 2 years, 10 years, etc.
Is this a Historical or Permanent Record?
Check all that apply:
Records have been scanned and/or duplicates are stored electronically.
Paper Records must be Stored at Warehouse until Retention is Met (Complete Label (exhibit A)for each box).
Records must be Microfilmed and Disposed in Recycle Bin (Complete Records Disposition Document(exhibit B)
with Signature on line#4)
Records must be Microfilmed and Shredded (Complete Records Disposition Document (exhibit B)with Signature
on line#4).
Duplicate and Return copy of Microfilm to Department after filming.
Records must be Disposed in Recycle Bin (Complete Records Disposition Document(exhibit B)with Signature on
line#4).
Records contain confidential information and must be Shredded (Complete Records Disposition Document
(exhibit B)with Signature on line#4).
Additional Instructions:
Records Picked up by: Date:
Records Technician
NO.
RECORDS DISPOSITION DOCUMENT
PAGE OF PAGES
1. AGENCY NAME and ADDRESS 2. AGENCY CONTACT (Name and Telephone Number)
( ) — Ext.
3. NOTICE OF INTENTION: The scheduled records listed in Item 5 are to be disposed of in the manner checked below(specify only
one).
❑ a. Destruction ❑ b. Microfilming and Destruction 0 c. Other
4. SUBMITTED BY: I hereby certify that the records to be disposed of are correctly represented below,that any audit requirements for
the records have been fully justified, and that further retention is not required for any litigation pending or imminent.
Signature Name and Title Date
5. LIST OF RECORD SERIES
f. g
a. b. c. d. e. Volume Disposition
Schedule Item Title Retention Inclusive In Action and
Dates Cubic Date
No. No. Feet Completed
After
Authorization
6. DISPOSAL AUTHORIZATION: Disposal for the above listed 7. DISPOSAL CERTIFICATE: The above listed records have been
records is authorized. Any deletions or modifications are indicated. disposed of in the manner and on the date shown in column g.
Signature Date
Custodian/Records Management Liaison Officer Date Name and Title
Witness