INSTRUCTIONS FOR COMPLETING THE FORM
REPORT ON RECORDS DESTROYED

Please read the instructions carefully before completing this form.

After completion, your agency must return this form to the State Archives, Records Services Branch, and retain a copy for reference to document the legal disposition of your records.

AGENCY means any state or local government entity.

This form should be used to report the destruction of records covered under General or Specific Record Retention/Disposition schedules. This form must be signed by the agency records officer or authorized representative.

  1. Enter your agency's name (Department of Health and Environmental Control) or the name of your political subdivision (Lexington County Sheriff's Office).
  2. Leave block 2 blank. This block will be completed by SC Department of Archives and History Record Analysts upon receipt of this form by the Records Services Branch.
  3. Enter any division or office identification which will clarify the records destroyed (Retirement System, State Law Enforcement Division).
  4. Be sure the date the form was completed appears in this space..
  5. The official making the report should sign here. The approving authority must be the agency's chief administrative officer or authorized representative. In most state agencies, this authorized representative may be the agency records officer. In local agencies this authorized representative may be the manager, administrator, elected department head or other designated official.
  6. Enter the exact record series title. Each series title should correspond to the one cited in the record retention schedule.
  7. Enter the appropriate record series/schedule number for each record series destroyed.
  8. Enter the earliest and latest dates covered by the records destroyed (2/1992-5/1993; or 1987-1990).
  9. Enter the volume (in cubic feet) of records destroyed. See 11 below. 
  10. Enter the date (month and year) of destruction 3/1993;1/1987; 12/1980). 
  11. Enter the total volume of records destroyed. Add figures entered in column 9.

Rev. 9/03