| 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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