HomeMy WebLinkAboutDisposition Forms_29-15_03/16/2015_Building •' '• • �• NO.
Revised : 1/22/14 PAGE ( OF PAGES
1. AGENCY 2. DEPARTMENT * 3. BUREAU
Village of Tequesta N/A
4. ADDRESS (Street, City, and Zip Code) 5. CONTACT (Name and Telephone Number)
345 Tequesta Drive Lori McWilliams, MMC
Tequesta, FL 33469 561- 768 -0440
6. SUBMITTED BY: I hereby certify that the records to be disposed of are 7. NOTICE OF INTENTION
correctly represented below, that any audit requirements for the records
have been fully justified, and that further retention is not required for any The scheduled records listed in Item 8 are to be disposed of in the
litigation pending or imminent. manner checked below (specify only one):
Only the Department Head has the authority to sign off on Item 6.
Signature 'fit - Date
r
Name 7,
Title �ir-1v��v� f3cci t op, Af7 ' 0 -' eC.lr�/�
8. LIST OF RECORD SERIES
a. b. C. d. e. f. g.
Schedule Item Title Retention Inclusive Volume Disposition
Item No. Dates in Action and Date
Cubic Completed After
Feet Authorization
CIA
9. DISPOSAL AUTHORIZATION: Disposal for the above listed records 10. DISPOSAL CERTIFICATE The above listed records have been
authorized. Any deletions or modifications are indicated disposed of in the manner and on the date shown in column g.
g, (Witness to the Records Disposition)
Signature n , Date ✓ �1 Signature Date 3 �s
Print Name: Lori McWilliams, MMC Print Name �64 1 lL
Print Title: Village Clerk Print Title
NOTE: Upon disposition retai this form for your records
Light gray shading indicates a field required to be completed by department.
Print Form
Light blue requires a signature