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Retention Schedule Change Request Form

Division/Department: Insert division or department name. Name of Requestor: Insert name of person requesting change. Type of Record (Name): Insert type of record to be changed.

Change Request: (Complete information regarding the request for change). Reason for Change to Retention Schedule: (in the space below provide an explanation for the change, i.e. legal, business, or audit requirement. Approved By signator, authorized signature or signer.

Division / Department Manager

PRINTED NAME Division / Department Manager. AUTHORIZED SIGNATURE DATE Records Administrator.

PRINTED NAME Records Administrator

AUTHORIZED SIGNATURE DATE

PRINTED NAME Legal

AUTHORIZED SIGNATURE DATE Change Effective in Schedules or Policy: DATE.