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Reproduce this.form as needed. <br /> North Carolina Department of Cultural Resources <br /> Division of Archives and Records <br /> Government Records Section <br /> REQUEST FOR CHANGE IN RECORDS SCHEDULE <br /> TO Assistant Records Administrator <br /> N.C. Division of Archives and Records <br /> Government Records Section <br /> 4615 Mail Service Center <br /> Raleigh, NC 27699-4615 <br /> FROM Name <br /> County <br /> Agency or department <br /> Phone <br /> INSTRUCTIONS <br /> Use this form to request a change in the records retention and disposition schedule governing the records of your <br /> agency. Submit the signed original,and keep a copy for your file.A proposed amendment will be prepared and <br /> submitted to the appropriate state and local officials for their approval and signature. Copies of the signed <br /> amendment will be sent to you for insertion in your copy of the schedule. <br /> CHANGE REQUESTED <br /> Add a new item <br /> Delete an existing item Standard Number Page Item Number <br /> Change an retention period Standard Number Page Item Number <br /> TITLE OF RECORDS SERIES IN SCHEDULE OR PROPOSED TITLE <br /> INCLUSIVE DATES OF RECORDS VOLUME OF RECORDS IN LINEAR INCHES <br /> DESCRIPTION OF RECORDS <br /> PROPOSED RETENTION PERIOD <br /> Requested by: <br /> Signature Title Date <br /> 116 <br />