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Here is the text we could read:

UNIFIED JUDICIAL SYSTEM SCHEDULED COURT RECORDS DISPOSAL CERTIFICATION REQUEST
[Pursuant to PA RJA 507(b)]

COUNTY

JUDICIAL DISTRICT

IF APPLICABLE

MAGISTERIAL DISTRICT

DISTRICT JUSTICE NAME

OFFICE OF ORIGIN

PERSON MAKING DISPOSAL REQUEST (RECORD CUSTODIAN)

ADDRESS

Approval Requested For:

  Records Destruction

  Records Transfer to PHMC

RECORD TITLE AND INCLUSIVE DATES (one series per form)

DESCRIPTION OF RECORD (include type of information contained and purpose of record)

RETENTION PERIOD IN SCHEDULE

PAGE AND SECTION IN SCHEDULE

HAVE ALL AUDIT REQUIREMENTS BEEN MET?

  Yes      

  No      

  Not Applicable

QUANTITY

No. of cartons 
No. of volumes 

No. of file drawers 

 TOTAL CUBIC FEET

Size:
Form:

  16mm
  Roll
  Other 

  35mm
  Cartridge

LOCATION OF SECURITY COPY

  Legal         

  Letter         

  Other 

Length 
Length 

  No
  Other 
  Cassette

  Fiche

HAVE RECORDS BEEN MICROFILMED?

  Yes      

ARCHIVAL MEDIUM UTILIZED

        Width 
        Width 

        Height 
        Height 

  OF AVERAGE CARTON
  OF AVERAGE VOLUME

Administrative Office of Pennsylvania Courts for permission to dispose of or transfer the records identified above.

  hereby  requests  that  the  Record  Retention  Officer  seek  approval  from  the

FOR USE BY RECORD CUSTODIAN

Signature

Phone  Number

FOR USE BY DISTRICT RECORDS RETENTION OFFICER

Authorization to dispose of or transfer the above-identified records is requested. If destruction of the records is requested, I certify that
the records have been reproduced on a medium approved by the Administrative Office of Pennsylvania Courts.

FOR USE BY THE ADMINISTRATIVE OFFICE OF PENNSYLVANIA COURTS

Signature

Judicial  District

Review by the Pennsylvania Historical and Museum Commission     

  is     

  is not     requested.

FOR USE BY THE PENNSYLVANIA HISTORICAL AND MUSEUM COMMISSION ONLY IF REVIEW REQUESTED BY AOPC

  Concur With Request

  Recommend Denial of Request

  Recommend Disposal Request Be Amended As Follows:

Date

Date

Date

Date

Signature

Signature

Approval is given for:

Comments/Amendments:

FOR USE BY THE ADMINISTRATIVE OFFICE OF PENNSYLVANIA COURTS

  Destruction
  Disapproved

  Destruction as Amended
  Retain Pending Further Instructions

  Transfer to PHMC

Date

Signature

Original must be sent to the Administrative Office of Pennsylvania Courts, 1515 Market Street, Suite 1414, Philadelphia, PA 19102.
Keep a copy for your records.

Title

Title

Title

(Untitled)

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Pennsylvania state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from www.pacourts.us (2023-03)
Page(s): 1
Fields(s): 69
Average fields per page: 69
Reading Level: Grade 11
LIST Grouping(s): Unknown

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

county was County (0.54 conf)
magisterial_district was Magisterial District (0.38 conf)
district_justice_name was District Justice Name (0.42 conf)
office_origin was Office of Origin (0.43 conf)
requestor was Requestor (0.35 conf)
users1_address_line_one was Address (1.00 conf)
unknown__1 was 1 (0.38 conf)
unknown__2 was 2 (0.38 conf)
record_title was Record Title (0.35 conf)
description was Description (0.40 conf)
retention_period was Retention Period (0.38 conf)
page_section was Page and Section (0.31 conf)
unknown__3 was 16 (0.38 conf)
unknown__4 was 17 (0.38 conf)
unknown__5 was 18 (0.38 conf)
cubic_feet was Cubic Feet (0.34 conf)
cartons was No. of cartons (0.42 conf)
volumes was No. of Volumes (0.36 conf)
file_drawers was No. of File Drawers (0.46 conf)
length__1 was Length (0.36 conf)
width__1 was Width (0.34 conf)
height__1 was Height (0.36 conf)
length__2 was Length2 (0.35 conf)
width__2 was Width2 (0.35 conf)
height__2 was Height2 (0.35 conf)
unknown__6 was 3 (0.38 conf)
unknown__7 was 4 (0.38 conf)
unknown__8 was 5 (0.38 conf)
other was Other (0.43 conf)
unknown__9 was 6 (0.38 conf)
unknown__10 was 7 (0.38 conf)
unknown__11 was 8 (0.38 conf)
unknown__12 was 9 (0.38 conf)
unknown__13 was 10 (0.38 conf)
other2 was Other2 (0.35 conf)
unknown__14 was 11 (0.38 conf)
unknown__15 was 12 (0.38 conf)
unknown__16 was 13 (0.38 conf)
unknown__17 was 14 (0.38 conf)
unknown__18 was 15 (0.38 conf)
other3 was Other3 (0.35 conf)
archival_medium was Archival Medium (0.29 conf)
location was Location (0.40 conf)
users1_name was Name (1.00 conf)
signature_date__1 was Date (1.00 conf)
phone_number was Phone Number (0.36 conf)
signature_date__2 was Date1 (1.00 conf)
unknown__19 was 19 (0.38 conf)
unknown__20 was 20 (0.38 conf)
signature_date__3 was Date2 (1.00 conf)
title__1 was Title (0.27 conf)
unknown__21 was 21 (0.38 conf)
unknown__22 was 22 (0.38 conf)
unknown__23 was 23 (0.38 conf)
amendment was Amendment (0.46 conf)
signature_date__4 was Date3 (1.00 conf)
title__2 was Title2 (0.35 conf)
unknown__24 was 24 (0.38 conf)
unknown__25 was 25 (0.38 conf)
unknown__26 was 26 (0.38 conf)
unknown__27 was 27 (0.38 conf)
unknown__28 was 28 (0.38 conf)
signature_date__5 was Date4 (1.00 conf)
title__3 was Title3 (0.35 conf)
users1_signature__1 was Signature2 (1.00 conf)
users1_signature__2 was Signature3 (1.00 conf)
users1_signature__3 was Signature4 (1.00 conf)
users1_signature__4 was Signature5 (1.00 conf)
users1_signature__5 was Signature6 (1.00 conf)

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

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Identified Data Fields:

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02