Fillable form per box: ARIZONA STATE ARCHIVES AND RECORDS (Arizona State Library, Arhives and Public Records)

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Page
of
Archives Rep Initial Here to Verify as Permanent
____
STATE ARCHIVES PERMANENT RECORD TRANSFER FORM
ARIZONA STATE ARCHIVES AND RECORDS MANAGEMENT
ARIZONA SECRETARY OF STATE
Instructions:
1. Complete and send entire form to the Arizona State Archives
2. Fill out only one transfer form for each retention schedule, not one
form per box
3. Attach any Restriction Notes, Servicing Agreements or Special
Instructions to the Transfer Form
4. The Agency must submit an inventory to the State Archives prior to
pick-up of records
The records described below and on any attached pages are transferred to the official
custody of the Arizona State Archives in accordance with ARS §41-
151.09. The
transferring agency certifies that any restrictions on the use of these records are listed
below. In accordance with ARS §41-151.09, custody of these records becomes the
responsibility of the Arizona State Library Archives and Public Records, Archives and
Records Management.
Short Description of Records being Transferred:
Transfer Information
State or County Agency:
Location of Records:
Restrictions?
Yes No
If Yes, Note ARS Justification:
Authorization to Transfer Records
Retention Schedule Number:
Justification if Not on Retention:
Signature of Records Officer:
Records Officer Name:
Title:
Date (MM/DD/YY):
Telephone:
Email:
Authorized Agent Signature (If different from Above):
Authorized Agent Name:
Date (MM/DD/YY):
Telephone:
Email:
Will the Arizona State Archives be the Servicing Agency for the Records: Yes No
If Not, sign here to agree to service all request for these items:
Transfer Inventory (Continue on Next Page if Necessary)
Please Indicate if there are any concerns about the condition of items being transferred: No Yes If Yes, Explain:
Number of Items to be Transferred:
Boxes:
Volumes:
Media:
Digital:
Record Dates
Type
Non-Paper Records Only
Media Type
Quantity/Size
Number of Files/Objects
File Format
For Archives Use Only
I certify that the records picked up match the transfer form and inventory
Signature___________________________________________________
Date _________________________
Record Group:
Director, Arizona State Library Archives and Public Records or Designee
Signature_____________________________________________
Date ______________________
Accession Number:
Series Number
Box, Volume, Media
Number
Other:
Form ARCH-TF (11/20/2019)
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Page
of
Transfer Inventory (Continued)
Record Dates
Type
Non-Paper Records Only
Media Type
Quantity/Size
Number of Files/Objects
File Format
Series Number
Box, Volume, Media
Number
Form ARCH-TF (11/20/2019)
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form per box: ARIZONA STATE ARCHIVES AND RECORDS (Arizona State Library, Arhives and Public Records)

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Completed 20 July 2020

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