HomeMy WebLinkAboutDisposition Forms_36-15_05/26/2015_Building Revised : 1/22/14 PAGE OF ', PAGES
1.AGENCY 2. DEPARTMENT 3. BUREAU
Village of Tequesta gul L q/w 6- P &A) / 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 Departme Head has the authority to sign off on Item 6.
Signatu Dates
/i-t� /� f /f 10E -t tC�l? ��'� �r C�,(� I�
Name
Title
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 Authoriz tion
24 Uf 0 i X)(r 1 l (TS 10 W41 MD )--Ct
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9. DISPOSAL AUTHORIZATION: Disposal for the above listed records 10. DISPOSAL CERTIFICATE The above listed records have been
authorized. Any or modifications are indicated disposed of in the manner and on the date shown in column g.
(Witness to the Records Disposition)
Signature iW� 1�/[(/ Date ,q (,��� SignatL d Date
Print Name: Lori McWilliams, MMC Print Name l
Print Title: Village Clerk Print Title
NOTE Upon disposition retain this form for your records
Light gray shading indicates a field required to be completed by department.
Print Form
Light blue requires a signature
Revised : 1/22/14 PAGE OF a, 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 Depart ent H d has the authority to sign off on Item 6.
Signa re Dates /� S
Name
Title P
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
ij
j U
9. DISPOSAL AUTHORIZATION: Disposal for the above listed records 10. DISPOSAL CERTIFICATE The above listed records have been
authorized. Lelet ions or modifications are indicated disposed of in the manner and on the date shown in column g.
(Witness to the Records Disposition)
Signature Date Signatu Date- �-
0 /
Print Name: Lori McWilliams, MMC Print Name Print Title: Village Clerk Print Title, �� �
9 i �' CCi �
NOTE: Upon disposition retain this form for your records
Light gray shading indicates a field required to be completed by department.
Print Form
Light blue requires a signature