Appendix C. COURT RECORDS DISPOSAL CERTIFICATION REQUEST

1. COURT	8. RETENTION PERIOD IN SCHEDULE
2. OFFICE OF ORIGIN	PAGE AND SECTION IN SCHEDULE
3. ADDRESS	9. QUANTITY TOTAL CUBIC FEET
	No. of cartons
	length width height
4. CONTACT PERSON 5. PHONE	(OF AVERAGE CARTON)
	No. of volumes
6. APPROVAL REQUESTED FOR:	length width height
Records Destruction	No. of file drawers
Records Transfer of PHMC	legal letter woodruff
	Other
7. RECORD TITLE AND INCLUSIVE DATES	10. HAVE RECORDS BEEN MICROFILMED
(One series per form)	Yes No
	Size: 16mm 35mm Other
	Form: Roll Cartridge
	Cassette Fiche Other
	LOCATION OF SECURITY COPY

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11. THIS IS TO REQUEST AUTHORIZATION TO DISPOSE OF THE ABOVE MENTIONED RECORDS INDICATED IN BOX 6.

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THIS ALSO CERTIFIES THAT ANY SECURITY MICROFILM GENERATED FROM THE RECORDS LISTED ON THIS REQUEST MEET THE MICROGRAPHICS STANDARDS APPROVED BY THE COUNTY RECORDS COMMITTEE.

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SIGNATURE OF COURT OFFICER TITLE DATE

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FOR PENNSYLVANIA HISTORICAL AND MUSEUM COMMISSION USE ONLY

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APPROVAL IS GIVEN FOR:	Destruction	Destruction as Amended
	Transfer to PHMC	Disapproved

COMMENTS/AMENDMENTS:

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SIGNATURE TITLE DATE