12.6.2022 Certificate of Records Destruction

ARIZONA STATE
A DIVISION OF THE ARIZONA SECRETARY OF STATE
LIBRARY, ARCHIVES AND PUBLIC RECORDS
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Revised 10/2022
An Equal Opportunity Employer
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.
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 the schedule number for the Retention Schedule you are following to determine eligibility for destruction.
Enter the record series number (five digit code) of  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.
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.
Mail or e-mail the original completed form to the Arizona State Library, Archives, and Public Records, Records Management Center.  
Polly Rosenbaum State Archives and History Building
1901 W. Madison St. • Phoenix, Arizona 85009 • Home Page: http://www.azlibrary.gov/records
Phone:  (602) 926-3820 •  E-Mail: records@azsos.libanswers.com

Eligible to 
Destroy 
Date
Revised 10/2022
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) 926-3820  •  E-Mail:  records@azsos.libanswers.com
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 
Record
Series
Number
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
A DIVISION OF THE ARIZONA SECRETARY OF STATE
LIBRARY, ARCHIVES AND PUBLIC RECORDS
City of El Mirage
City Clerk
Housing Files:  Juana Andres, Juana Vargas
000.12.57
12
12.6.2022
Paper
2
American Veteran Traveling Tribute Appearance Contract
GS 1018
30678
11.2.2016
11.6.2016
11.7.2022
Paper
1
Sunland Asphalt YMCA Agreement
GS 1018
30678
11.8.2012
11.7.2013
11.8.2022
Paper 
1
Haydon Construction City Hall Construction
GS 1018
30678
2.17.2016
11.8.2018
11.8.2022
Paper 
1
City Clerk
623.876.2943
santes@elmirageaz.gov
12.6.2022
SIGN
Sharon Antes