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226 <br /> r ■�■ GOVERNMENT RECORDS SECTION <br /> " NC DEPARTMENT OF STATE RECORDS CENTER <br /> ■NEW NATURAL AND CULTURAL RESOURCES <br /> ■ ■o■ <br /> ncdcr.gov 4615 Mail Service Center, Raleigh NC 276994165 . . .•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 /> Requestor name <br /> Location and Agency[e.g., County/Municipality+ Department of Social Services] <br /> Phone and email <br /> Mailing Address <br /> Specify title and edition of records retention schedule being used: <br /> ❑Add a new item I <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 /> i <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 /> DIVISION OF ARCHIVES AND RECORDS—GOVERNMENT RECORDS SECTION A-19 <br /> http://archives.ncdcr,gov <br /> MAILING ADDRESS: Telephone(919)814-6900 LOCATION: <br /> 4615 Mail Service Center Facsimile(919)715-3627 215 N.Blount Street <br /> Raleigh,N.C. 276994615 State Courier 51-81-20 Raleigh,N.C. 27601-2823 <br />