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Cy Name Agency Address Agency City, State and Zip Code SECRETARY OF STATE DIVISION OF ARCHIVES RECORDS MANAGEMENT & HISTORY P.O. BOX 94125, Capitol Station Baton Rouge, Louisiana 70804-9125 2. Records Officer and Title 3. Date 6/20/2003 Jane Doe, Records Management Officer 4. Transfer to: Phone No. X (225) 111-1111 X 123 Records Center 5. No. of Boxes Transferred 7. RECORDS CENTER BOX NO. 8. AGENCY BOX NO. 12 9. DATE OF RECORDS TO BE TRANSFERRED Other: 6. Disposal Date 7/2006 V1.

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