STATE OF OKLAHOMA

ARCHIVES AND RECORDS COMMISSION

AGENCY NOTICE OF INTENT TO DESTROY RECORDS THAT HAVE BEEN IMAGED
	
Name of Agency

	Date Prepared

	Date Received (leave blank)	
Name of Division

	Phone Number	
Schedule or
RDA Number	Series
Number	
Series Title	Inclusive Dates
of Records	Disk
Number	

	

	

	

	

	
	
I hereby certify that for the above listed records, all state and federal audits have been completed, all applicable audit reports have been accepted and resolved by all applicable federal and state agencies; all records have been successfully entered on disk and a back up copy of the disk is stored in an off site storage area that meets all criteria specified in Archives and Records Commission Rule 60:10-8-5(e), or in lieu of a back up disk, all data is being maintained on permanent microfilm being stored off site that meets all standards for authenticity, photographic quality, and bibliographic integrity required by Archives and Records Commission Rule 60:10-7-2; and no legal actions are pending.		

_______________________________________________
Signature of Agency Official

______________________________________________
Title of Agency Official

____________________  APPROVED

____________________  DENIED

______________________________________________
Signature of State Records Administrator or Designee

______________________________________________
Date
	
WHITE     - Archives and Records Commission Copy
GREEN    - Records Management Division Copy
YELLOW  - Agency Copy	ARC Form 12
Rev.    07/99	

SUBMIT ALL THREE COPIES TO THE STATE RECORDS ADMINISTRATOR