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Reproduce this form as needed. <br />North Carolina Department of Cultural Resources <br />Division of Archives and Records <br />Government Records Section <br />REQUEST FOR CHANGE IN RECORDS SCHEDULE <br />TO Assistant Records Administrator <br />N.C. Division of Archives and Records <br />Government Records Section <br />4615 Mail Service Center <br />Raleigh, NC 27699 -4615 <br />FROM Name <br />County <br />Agency or department <br />Phone <br />INSTRUCTIONS <br />Use this form to request a change in the records retention and disposition schedule governing the records of your <br />agency. Submit the signed original, and keep a copy for your file. A proposed amendment will be prepared and <br />submitted to the appropriate state and local officials for their approval and signature. Copies of the signed <br />amendment will be sent to you for insertion in your copy of the schedule. <br />CHANGE REQUESTED <br />Add a new item <br />Delete an existing item Standard Number Page Item Number <br />Change an retention period Standard Number Page Item Number <br />TITLE OF RECORDS SERIES IN SCHEDULE OR PROPOSED TITLE <br />INCLUSIVE DATES OF RECORDS <br />VOLUME OF RECORDS IN LINEAR INCHES <br />DESCRIPTION OF RECORDS <br />PROPOSED RETENTION PERIOD <br />Requested by: <br />Signature Title Date <br />116 Attachment number 1 <br />G -3 Page 170 <br />