Revised 9/2019 An Equal Opportunity Employer
LIBRARY, ARCHIVES AND PUBLIC RECORDS
Enter the item number from the authorized schedule you are following.
Enter the earliest date of records being transferred under the Records Start Date column and the latest date for the records being transferred
under the Records End Date column.
Enter the format of the records to be transferred under the Format: Paper, Digital, Microfilm column.
A DIVISION OF THE ARIZONA DEPARTMENT OF STATE
Enter the amount of records being transferred under the # of Files, Boxes, Reels; Electronic File Size column.
PART 2: CHAIN OF CUSTODY CERTIFICATION
Do not complete Part 2 of the form until you have received signed authorization to transfer the records. If it is a one time transfer, do
not sign until the transfer has been completed.
Use this form ONLY for records being transferred between different public bodies.
In the top section enter the name of the Public Body transferring the records and the body receiving the records. Include any subdivision
breakdown for division, department or unit.
Fill in the contact information for the requestor of the authorization approval.
Under Transfer status indicate it is a one time transfer or a reoccurring transfer between bodies. RMC will assign an expiration date for
List the Record Series titles being transferred using the exact record series name(s) found on the approved Retention Schedule being followed.
When the transfer has occurred, complete the certificate section of the form and mail the original to the Arizona State Library, Archives, and
Public Records, Records Management Center.
Include the names, titles, phone number and e-mail for both transferring and receiving public bodies. Both public bodies must sign and date the
Polly Rosenbaum State Archives and History Building
1901 W. Madison St. • Phoenix, Arizona 85009 • Home Page: http://www.azlibrary.gov/records
Phone: (602) 926-3815 • FAX: (602) 256-2838 • E-Mail: firstname.lastname@example.org