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Eligible to Destroy Date Revised 01/2019 An Equal Opportunity Employer CERTIFICATE OF RECORDS DESTRUCTION 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 Records Officer Signature: E-Mail: Date: Records Officer Approval (type or print name): Title (type or print): Phone : Department Office/Unit Record Series Title as Stated on Approved Schedule Schedule Number or Date Item # Records Start Date Records End Date Format: Paper, Digital, Microfilm # of Files, Boxes, Reels; Electronic File Size 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 Division ARIZONA STATE LIBRARY, ARCHIVES AND PUBLIC RECORDS A DIVISION OF THE ARIZONA SECRETARY OF STATE Dr. Ted Hale, State Archivist Director, State Archives and Records Management CITY OF EL MIRAGE FINANCE FINANCE FINANCE Accounts Payable and Receivable Records, All other public bodies GS-1017 Rev. 1 10057 07/01/2015 06/30/2016 07/01/2019 Paper 1 Box Accounts Payable and Receivable Records, All other public bodies GS-1017 Rev. 1 10057 07/01/2015 06/30/2016 07/01/2019 Paper 1 Box Accounts Payable and Receivable Records, All other public bodies GS-1017 Rev. 1 10057 07/01/2015 06/30/2016 07/01/2019 Paper 1 Box Accounts Payable and Receivable Records, All other public bodies GS-1017 Rev. 1 10057 07/01/2015 06/30/2016 07/01/2019 Paper 1 Box Accounts Payable and Receivable Records, All other public bodies GS-1017 Rev. 1 10057 07/01/2015 06/30/2016 07/01/2019 Paper 1 Box Accounts Payable and Receivable Records, All other public bodies GS-1017 Rev. 1 10057 07/01/2015 06/30/2016 07/01/2019 Paper 1 Box Accounts Payable and Receivable Records, All other public bodies GS-1017 Rev. 1 10057 07/01/2015 06/30/2016 07/01/2019 Paper 1 Box Accounts Payable and Receivable Records, All other public bodies GS-1017 Rev.1 10057 07/01/2015 06/30/2016 07/01/2019 Paper 1 Box Financial Management Records GS-1017 Rev. 1 10071 07/01/2015 06/30/2016 07/01/2019 Paper 1 Box evenue Service (IRS) and Department of Revenue (ADOR) Forms an GS-1017 Rev. 1 10076 07/01/2014 06/30/2015 07/01/2019 Paper 1 Box Dana Williams Interim Finance Director 623-876-2951 dwilliams@elmirageaz.gov 11/16/21 Dana Williams Digitally signed by Dana Williams Date: 2021.11.16 18:22:28 -07'00' ARIZONA STATE LIBRARY, ARCHIVES AND PUBLIC RECORDS A DIVISION OF THE ARIZONA SECRETARY OF STATE Dr. Ted Hale, State Archivist 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Revised 01/2019 An Equal Opportunity Employer Director, State Archives and Records Management 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. INSTRUCTIONS 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.