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Facility Name
The information described below was destroyed in the normal course
of business pursuant to a proper retention schedule and destruction
policies and procedures.
Date of destruction:____________________________________________
Description of records or record series disposed of: ______________________________
___________________________________________________________________________________
___________________________________________________________________________________
Inclusive dates covered:__________________________________________
Method of destruction:
( ) Burning ( ) Shredding ( ) Pulping
( ) Demagnetizing ( ) Overwriting ( ) Pulverizing
( ) Other:______________________________________________________
Records destroyed by:___________________________________________
Witness signature:______________________________________________
Department manager:_____________________________________________
Note: This sample form is provided for discussion purposes only.
It is not intended for use without advice of legal counsel.
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