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w' <br /> 0 1 r N( `.1'1...1 .AR 1..I STATE RECD)S CENTER <br /> IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII 1111111 IIIIIIIIIIIIII <br /> 01 III 9 „��� �� III VIII III lag IIII 1 1 0000 0000 <br /> I II WW lip VIII VIII I uuui iuuui 777777 <br /> REQUEST FOR CHANGE IN RECORDS SCHEDULE <br /> TO Assistant Records Administrator <br /> 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 /> Mailing address <br /> Phone or email <br /> INSTRUCTIONS <br /> Use this form to request a change in the records retention and disposition schedule governing the records of <br /> your agency. Submit the signed original, and keep a copy for your file. A proposed amendment will be <br /> prepared and submitted to the appropriate state and local officials for their approval and signature. Copies of <br /> the signed 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 APPROXIMATE VOLUME OF RECORDS <br /> DESCRIPTION OF RECORDS <br /> PROPOSED RETENTION PERIOD <br /> Requested by: <br /> Signature Title Date <br /> Physical Address: State Couciec 51-81-20 <br /> 215 N Blount Street Facsimile(919)715-3627 <br /> Raleigh,N . 27601 cecocds @ncdcc.gov <br />