AZ Certificate of Records Destruction

ARIZONA STATE
LIBRARY, ARCHIVES AND PUBLIC RECORDS
A DIVISION OF THE ARIZONA SECRETARY OF STATE

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Archives and Public Records

CERTIFICATE OF RECORDS DESTRUCTION

As authorized under ARS §41-151.19, "...A report of records destruction that includes a list of all records disposed of shall be filed at least annually
with the state library on a form prescribed by the state library."

Failure to comply with these procedures is a violation of ARS §41-151.19.

Public Body City of El Mirage

Division
Department H uman Resources Office/Unit
Eligible to Format: # of Files, Boxes,
Record Series Title as Stated on Approved Schedule Schedule Number Item # Records Start) Records End Destroy Paper, Digital, | Reels; Electronic
or Date Date Date "
Date Microfilm File Size
Employee Personnel Records, Official Copy GS-1006 (Rev. 2) | 20704 | 3/27/2006 12/3/2015 12/30/2020 Paper 9 files
Hiring/Selection Records, Peace Officers GS-1006 (Rev. 2) | 20721 | 9/15/2016 8/14/2017 8/14/2020 Paper 2 files
Hiring/Selection Records, All Others GS-1006 (Rev. 2) | 20722 | 3/7/2018 6/18/2018 | 12/18/2020 Paper 3 files
|-9 Forms GS-1006 (Rev. 2) | 20730 | 4/29/2002 1/23/2020 1/23/2021 Paper 12 files
Records Officer Approval (type or print name): Title (type or print): Phone:
Dawn Kurek Human Resources Director 623-876-2949
Rec nw ee Signature: E-Mail: Date:
Wo cede dkurek@elmirageaz.gov 01/19/2021

Revised 06/2020

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

An Equal Opportunity Employer

ARIZONA STATE @ tg
LIBRARY, ARCHIVES AND PUBLIC RECORDS EGP
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Archives and Public Records

INSTRUCTIONS

Use this form ONLY for records that were destroyed and were on a current approved Retention Schedule.

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In the top section enter the name of your Agency or Public Body, and include any subdivision breakdown for division, department or unit.

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 Fi iles, Boxes, Reels or Electronic File Size column.

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.

10. 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.

11. 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

Revised 06/2020 An Equal Opportunity Employer