HomeMy WebLinkAboutDisposition Forms_54-15_12/14/2015_Building •' • • �• NO. 5 t — - 5 •
Revlacu : 1/22/14 PAGE OF PAGES
1. AGENCY 2. DEPARTMENT D �—� 3. BUREAU
Village of Tequesta �(,� b E C 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 Dep ment Head has the authetity to sign off on Item 6.
Signat e Date rL . /K, /S Z
Name 7 - / "
1 M I FAI V �(-� v '
Title 6 ` iA of r J0 A-
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
�Ui LZ I" 1 k , 1 Iv yr S
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.
n / (Witness to the Records Disposition
Signature Date lA, y �� Signat ate `'S
Print Name: Lori McWilliams, MMC 11 Print UM * Ajl w S
Print Title: Village Clerk Print Title . &b&- ktA 17
( 0
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