Fillable Form 1.: (Arizona State Library, Arhives and Public Records)

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Form 1.: (Arizona State Library, Arhives and Public Records)

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The Form 1.: (Arizona State Library, Arhives and Public Records) form is 3 pages long and contains:

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  • 6 check-boxes
  • 53 other fields

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Revised 9/2019 An Equal Opportunity Employer
ARIZONA STATE
LIBRARY, ARCHIVES AND PUBLIC RECORDS
INSTRUCTIONS
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.
PART 1: APPROVAL
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
reoccurring transfers.
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
certificate.
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: records@azlibrary.gov
ARIZONA STATE
LIBRARY, ARCHIVES AND PUBLIC RECORDS
A DIVISION OF THE ARIZONA DEPARTMENT OF STATE
PART 1: APPROVAL REQUEST
TRANSFERRING BODY:
RECEIVING BODY:
Transfer status: One time request Recurring transfer Expiration date for ongoing transfer:
Revised 9/2019 An Equal Opportunity Employer
Public Body Title:
Records Officer Name (type or print):
Title (type or print):
As authorized under ARS §41.151.18 and §39-121.01 (c), ...Each public body shall be responsible for the preservation, maintenance and care of that body's
public records, and each officer shall be responsible for the preservation, maintenance and care of that officer's public records. It shall be the duty of each
such body to carefully secure, protect and preserve public records from deterioration, mutilation, loss or destruction, unless disposed of pursuant to sections
41-151.15 and 41-151.19.
Public Body Title:
Records Officer Name (type or print):
Title (type or print):
Address:
E-Mail:
Record Series Title as Stated on Approved Schedule
Schedule Number
or Date
Item #
Records Start
Date
Records End
Date
Format:
Paper, Digital,
Microfilm
# of Files, Boxes,
Reels; Electronic
File Size
Address:
E-Mail:
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: records@azlibrary.gov
ARIZONA STATE
LIBRARY, ARCHIVES AND PUBLIC RECORDS
A DIVISION OF THE ARIZONA DEPARTMENT OF STATE
Transfer records to Arizona State Library, Archives and Public Records.
Verified with receiving body's Records Officer
AUTHORIZED BY:
Dr. Dennis Preisler, State Archivist Date Approved
Records Analyst (or designee) Date Approved
TRANSFERRING PUBLIC BODY:
RECEIVING PUBLIC BODY:
Revised 9/2019 An Equal Opportunity Employer
PART 2: CHAIN OF CUSTODY CERTIFICATION
ACTION AUTHORIZED
CHAIN OF CUSTODY CERTIFICATE THAT RECORDS HAVE BEEN TRANSFERRED
THIS PORTION IS NOT TO BE FILLED OUT UNTIL AUTHORIZATION HAS BEEN SIGNED BY LAPR
Records Officer Name (type or print):
Title (type or print):
Phone :
Continue to hold until:
Transfer records to:
Records Officer Name (type or print):
Title (type or print):
Phone :
Records Officer Signature:
Date:
E-Mail:
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: records@azlibrary.gov
Records Officer Signature:
Date:
E-Mail:
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Form 1.: (Arizona State Library, Arhives and Public Records)

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Completed 20 July 2020

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