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Local Government Public Records Destruction Log
The purpose of this form is to document compliance and reasonable accountability by verifying that specific public records have met current, approved minimum
retention periods before being destroyed pursuant to RCW 40.14.070, WAC 434 - 610 -070, and WAC 434 - 640 -010, -020, and -030 Please fill out this form when
destroying all public records whose minimum retention is other than "Retain until no longer needed for agency business then destroy" (such as records covered in
the "Records with Minimal Retention Value" section of the Local Government Common Records Retention Schedule (CORE).
Legal Disposition Authority (taken from Records Retention Schedule) Agency Records
Date Method(s) of
Records Series Records Series Records Retention Description Minimum Destruction
Title DAN Schedule volume, Minimum Retention Period (Bo m numbers, Dates Covered
volume, etc.) Retention (See examples,
Met below*)
LMO
Wq*T P_ pl4A— 12�,�ards Il°� �00 Rec V
wZ aq
Si d5 c0,.Sals ds - G� �5 C) 0<1 CA cl i
k AR Ck V A bo
49
*Examples of methods of destruction: electronic deletion, in -house OR outside contractor shredding, secure recycling, other (describe)
Statement: The public records listed above have met their minimum retention period(s), are not subject to ongoing or reasonably
anticipated litigation or public records requests, are not needed for auditor other agency business, and shall be destroyed.
The individual responsibin for inventorying the listed records must sign b prior to the Records Manager's approval:
Employee Signature: inted Name: `�5 Division:
The Records Manager must si t e approval of this reques prior to the destruction of the listed records:
Records Manager Signature: v\ - `'/`�J Printed Name: yy �s Date Approved: LP W 1-4
g g _J
The person /people resp sible for the destruction of records must sign upon destruction of the lis records:
Employee Signature: Printed Name: V Date Records Destroyed:
Vendor Business Name (if used): Phone:
Vendor Signature: Printed Name: Date Records Destroyed:
The retention and disposition action for this Public Records Destruction Log is "Retain for the life of the agency" pursuant to CORE series GS50- 09 -06.
This sample form was prepared by Washington State Archives as a courtesy to local government agencies in January, 2014.
It may be modified to meet individual agency needs.