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105 <br /> •aE-10•0,'■ GOVERNMENT RECORDS SECTION <br /> NC DEPARTMENT OF <br /> ■iui NATURAL AND CULTURAL RESOURCES STATE RECORDS CENTER <br /> ■1no� <br /> ncdcr.gov 4615 . .•• . . . .•11 <br /> Request for Change in Local Government Records Schedule <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 prepared <br /> and 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 /> AGENCY INFORMATION <br /> RMATIt <br /> Requestor name <br /> Location and Agency[e.g., County/Municipality+ Department of Social Services] <br /> Phone and e-mail <br /> Mailing Address <br /> 'r <br /> CHANGE REMWESTE© <br /> Specify title and edition of records retention schedule being used: <br /> H <br /> Add a new item <br /> Delete an existing item Standard Number Page Item Number <br /> ❑ Change a retention period Standard Number Page Item Number_ <br /> Title of Records Series in Schedule or Proposed Title: <br /> Inclusive Dates of Records: Proposed Retention Period: <br /> Description of Records: <br /> Justification for Change: <br /> Requested by: <br /> Signature Title Date <br /> Approved by: <br /> Signature Requestor's Supervisor Date <br /> A-19 <br />