State Form 16 "Records Destruction Notification" - Indiana

What Is State Form 16?

This is a legal form that was released by the Indiana Archives and Records Administration - a government authority operating within Indiana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2015;
  • The latest edition provided by the Indiana Archives and Records Administration;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of State Form 16 by clicking the link below or browse more documents and templates provided by the Indiana Archives and Records Administration.

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Download State Form 16 "Records Destruction Notification" - Indiana

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INDIANA ARCHIVES AND RECORDS ADMINISTRATION
RECORDS DESTRUCTION NOTIFICATION
INDIANA STATE RECORDS CENTER
6400 East 30th Street
State Form 16 (R14 / 6-15)
Indianapolis, IN 46219
Telephone: (317) 591-5326
Fax: (317) 591-5328
INSTRUCTIONS:
1.
Please type or print legibly.
2.
Forward completed notification to address in the upper right corner of this form.
3.
Signature must be signed by hand.
4.
If this notification was sent to you by the Records Center, you have six (6) weeks to respond.
Otherwise, the records will be destroyed automatically. You may fill out State Form 47167, “Do Not Destroy
Records,” and send to the Records Center along with this State Form 16, “Records Destruction Notification,”
if the records are not to be destroyed.
These records will be destroyed in accordance with IC 5-15-5.1 and current retention schedule.
NOTE: Items marked with an asterisk (*) are required for billing purposes.
AGENCY INFORMATION
Name of agency
Name of division
Signature of Agency Records Coordinator
Date of signature (month, day, year)
Printed name of Agency Records Coordinator
RECORDS INFORMATION
Records series number
Records series title
Latest date of records (month and year)
Destruction due date (month, day, year)
Total cubic feet of records to be destroyed
Request for courtesy destruction?
Yes
No
Type of media
Container / box number(s)
Location
Accession number (if applicable)
Request for shredding?
Paper
Electronic
Yes
No
Film
Other
Destroyed by (signature):
Date of destruction (month, day, year)
Activity number
Source number
Category number
Sub-category number
Locality number
Business unit *
Fund *
Department *
Program number *
Printed name
FOR RECORDS CENTER USE ONLY
Approved
Not Approved (see attached for explanation)
Transfer to State Archives (do not destroy)
Signature of Records Center staff
Date of signature (month, day, year)
Printed name of Records Center staff
DISTRIBUTION: White – Records Center (file); Canary – Agency after disposal of records; Pink – Records Center transmittal; Goldenrod – With records
Reset Form
INDIANA ARCHIVES AND RECORDS ADMINISTRATION
RECORDS DESTRUCTION NOTIFICATION
INDIANA STATE RECORDS CENTER
6400 East 30th Street
State Form 16 (R14 / 6-15)
Indianapolis, IN 46219
Telephone: (317) 591-5326
Fax: (317) 591-5328
INSTRUCTIONS:
1.
Please type or print legibly.
2.
Forward completed notification to address in the upper right corner of this form.
3.
Signature must be signed by hand.
4.
If this notification was sent to you by the Records Center, you have six (6) weeks to respond.
Otherwise, the records will be destroyed automatically. You may fill out State Form 47167, “Do Not Destroy
Records,” and send to the Records Center along with this State Form 16, “Records Destruction Notification,”
if the records are not to be destroyed.
These records will be destroyed in accordance with IC 5-15-5.1 and current retention schedule.
NOTE: Items marked with an asterisk (*) are required for billing purposes.
AGENCY INFORMATION
Name of agency
Name of division
Signature of Agency Records Coordinator
Date of signature (month, day, year)
Printed name of Agency Records Coordinator
RECORDS INFORMATION
Records series number
Records series title
Latest date of records (month and year)
Destruction due date (month, day, year)
Total cubic feet of records to be destroyed
Request for courtesy destruction?
Yes
No
Type of media
Container / box number(s)
Location
Accession number (if applicable)
Request for shredding?
Paper
Electronic
Yes
No
Film
Other
Destroyed by (signature):
Date of destruction (month, day, year)
Activity number
Source number
Category number
Sub-category number
Locality number
Business unit *
Fund *
Department *
Program number *
Printed name
FOR RECORDS CENTER USE ONLY
Approved
Not Approved (see attached for explanation)
Transfer to State Archives (do not destroy)
Signature of Records Center staff
Date of signature (month, day, year)
Printed name of Records Center staff
DISTRIBUTION: White – Records Center (file); Canary – Agency after disposal of records; Pink – Records Center transmittal; Goldenrod – With records