A DIVISION OF THE ARIZONA SECRETARY OF STATE
LIBRARY, ARCHIVES AND PUBLIC RECORDS
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Revised 06/2020
An Equal Opportunity Employer
If additional pages are needed for reporting, please save and print the form and fill in the corresponding page numbers at the top of the form.
At the bottom of the form the Agency or Public Body Records Officer must sign and date the Certificate of Destruction to certify the records were
properly destroyed.
Use this form ONLY for records that were destroyed and were on a current approved Retention Schedule.
In the top section enter the name of your Agency or Public Body, and include any subdivision breakdown for division, department or unit.
Mail or e-mail the original completed form to the Arizona State Library, Archives, and Public Records, Records Management Center. Fax copies
are acceptable only if the received fax is legible.
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
List the Record Series titles associated with the destruction using the exact record series name(s) found on the approved Retention Schedule being
followed.
Enter either the schedule number or approved date for the Retention Schedule you are following to determine eligibility for destruction.
Enter the item number from the authorized schedule you are following.
Enter the earliest date of records you are requesting to destroy under the Records Start Date column and the latest date for the records you are
requesting to destroy under the Records End Date column.
Enter the date the records were eligible for destruction.
Enter the format of the records to be destroyed under the Format: Paper, Digital, Microfilm column.
Enter the amount of records being destroyed under the Number of Files, Boxes, Reels or Electronic File Size column.
