CERTIFICATE OF RECORDS DESTRUCTION

2. Date*
   Date

3. Your Name*

4. Department Name or Division*
   -- Select One --AccountingAdministrative ServBldg-InspecCIP-Const PlanningCommunicationsCustomer RelationsEconomic DevelopmentEngineering ServEnvironmental ServFacilities MgmtFinancial ServFire-EMS ServHuman ResourcesInformation TechLegislative ServLibrary ServMunicipal CourtParks-Rec ServPlanning ServPolice ServPublic WorksTown ManagerTreasury Operations

6. Are/Were the records eligible for destruction in accordance with the Town's Retention Schedule (Texas State Library & Archives Commission-TSLAC)?*

   1. Yes
   2. No
   3. Not sure

   If no or not sure, contact the Records Mgmt Coor/Deputy Town Secretary or review the Retention Schedule.

7. TSLAC
   Retention Schedule

9. Have the records already been destroyed?*

   1. Yes
   2. No

10. If yes, by what method?
    -- Select One --Electronically deletedShreddedTrashRecycledOther

11. If other method, describe:

13. 1ST ENTRY

15. Records Series Title*

    This is the title of the records as defined by TSLAC

16. Records Series Number

    This is the Record Number as defined by TSLAC (i.e. GR1000-3d)

17. Records Description*

18. Date/date range of records?*

20. 2ND ENTRY

22. Title

23. Series Number

24. Description

25. Date/Date Range

27. 3RD ENTRY

29. Title

30. Series Number

31. Description

32. Date/Date Range

34. 4TH ENTRY

36. Title

37. Series

38. Description

39. Date/Date Range

41. 5TH ENTRY

43. Title

44. Series

45. Description

46. Date/Date Range

48. 6TH ENTRY

50. Title

51. Series

52. Description

53. Date/Date Range

55. Who authorized the destruction of the records?*

    Name of supervisor or dept. head that authorized the destruction of records.

57. Do you have space limitations where you are unable to store the records until the Town-wide destruction day?*

    1. Yes
    2. No
    3. Not Applicable

58. If no, where are the records located?

    This information would be used to generate a facilities request to have the records transferred to records storage.

Leave This Blank:


60. 1. Receive an email copy of this form.
61. Email address

    This field is not part of the form submission.

62. Submit

* indicates a required field