Commonwealth of Virginia Certificate of Records Destruction
(Form RM-3 Nov 99)
Records Management and Imaging Services Division
800 East Broad Street, Richmond, VA 23219-8000
(804) 692-3600
This form documents the destruction of public records in accordance with the Virginia Public Records Act, § 42.1-86.1 of the Code of Virginia.
INSTRUCTIONS ON BACK.
1) Agency / Locality
2) Division / Department / Section
3) Person Completing Form
4) Address
5) Phone No.
6) Records to Be Destroyed
a) Schedule and
Records Series No.
b) Records Series Title
c) Date Range (mo/yr)
d) Location
e) Volume
f) Method of
Destruction
DESTRUCTION APPROVALS
NOTE: Public records may not be destroyed without receiving prior approval from your agency or locality Records Officer.
We certify that the records listed above have been retained for the scheduled retention period, required audits have been completed, and no pending or ongoing litigation or investigation involving these records is known to exist.
7.
APPROVING OFFICIAL (PRINT NAME) SIGNATURE DATE
8.
DESIGNATED RECORDS OFFICER (PRINT NAME) SIGNATURE DATE
9. RECORDS DESTROYED BY:
NAME (PRINT OR SIGNATURE) DATE OF DESTRUCTION
