STATE OF OKLAHOMA

ARCHIVES AND RECORDS COMMISSION

AGENCY NOTICE OF INTENT TO DESTROY RECORDS THAT HAVE BEEN MICROFILMED
	
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	Reel
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 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 5
Rev.    07/99	
SUBMIT ALL THREE COPIES TO THE STATE RECORDS ADMINISTRATOR
This Form MUST be accompanied by ARC Form 5A, "Microfilm Quality Evaluation"