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Reproduce this form as needed. <br />North Carolina Department of Cultural Resources <br />Division of Historical Resources <br />Government Records Branch <br />REQUEST FOR CHANGE IN RECORDS SCHEDULE <br />TO Assistant Records Administrator <br />N.C. Division of Historical Resources <br />Government Records Branch <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 agency. <br />Submit the signed original, and keep a copy for your file. A proposed amendment will be prepared and submitted to the <br />appropriate state and local officials for their approval and signature. Copies of the signed amendment will be sent to you for <br />insertion in your copy of the schedule. <br />I:HAN(iE Kr:(?UESTED <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 VOLUME OF RECORDS IN LINEAR INCHES <br />DESCRIPTION OF RECORDS <br />PROPOSED RETENTION PERIOD <br />Requested by: , <br />Signature Title Date <br />75 Attachment number 1 <br />F-12 Page 326 of 627 <br />