Montgomery College
Records Management, OIT
9221 Corporate Boulevard
Rockville
, MD 20850
CERTIFICATE OF IN-OFFICE
RECORDS DESTRUCTION
Use this form to document the destruction of public records that have been retained in your MC Office/Department in accordance with the College’s
Records Retention Schedule. Send completed form to the Records Management Office, OIT.
1. College Office / Department
2. Administrator / Records Point of Contact
3. Person Completing Form
4. Address
5. Telephone Number &
Extension
6. Records to Be Destroyed
a) Schedule #, Record
Grou
# and Item #
b) Records Series Title
c) Inclusive Dates of
Records Destro
ed
e) Date of
Destruction
f) Destruction Method
Enter the numbers from the
fields of the same names on
the College’s Records
Retention Schedule.
Example: 11-117-2
Enter the series title of the item exactly as it appears on the College’s Records
Retention Schedule.
Example: 11-117-2 refers to Facilities Records Retention Schedule #11, Record
Group # 117, and Item # 2.
The series title is: Centralized Maintenance Accounts Files.
Enter oldest date to
most recent date.
Date that you
destroyed the
records.
Enter means used to dispose of
the records. Confidential,
sensitive material must be cross-
shredded, burned or pulped.
DESTRUCTION APPROVALS: By signing, I certify that the records listed above have been retained for the scheduled retention period in our office/department, required
audits have been completed, and no pending or ongoing litigation or investigation involving these records is known to exist.
7. Administrator (Print)
Signature
Date
8. Records
Destroyed By (Print) Signature Date
