STATE OF OKLAHOMA

ARCHIVES AND RECORDS COMMISSION

AGENCY NOTICE OF INTENT TO DESTROY RECORDS
	
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	Volume
Cubic Feet	

	

	

	

	

	
	
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 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 4
Rev.    07/99	
SUBMIT ALL THREE COPIES TO THE STATE RECORDS ADMINISTRATOR