Fill and Sign the Complete One Form for Each Record Series that is Being Offered to

GF-110, 03/04 Notification to the State Historical Society (Disposition of Obsolete Records) SCR 72.04 This form shall not be modified. It may be supplemented with additional material. 1. Complete one form for each record series that is being offered to the Historical Society. 2. Retain one copy and send a copy to the State Archivist, State Historical Society of Wisconsin, 816 State St., Madison, WI 53706-1482 3. The State Historical Society will return a copy of the form indicating whether it accepts or declines the records. 4. If the Historical Society indicates interest in the records, a copy should be kept with the records and used as a transmittal sheet. Notification to the State Historical Society (Disposition of Obsolete Records) Archives Accession Number County Date Notification Submitted Office which created the records: C Clerk of Court Register in Probate Juvenile Clerk Address Authorized Signature Telephone Number Name of Person to Contact for Additional Information Telephone Number E-mail Address · If record is one of items 1-60 described in SCR Chapter 72.01, indicate item number in box No. 2 below. · If record is not included in items 1-60, please describe in box No. 9 below. 1. Record Series Title 2. SCR Item number (1-60) 3. Dates Included 4. Case Numbers / I.D. 5. Quantity (numbers of boxes, volumes, etc.) 6a. Format of records being offered: 1. paper 3. microfiche 5. other (specify) 2. microfilm 4. electronic 6b. Is this series also available on microfilm or other microform? yes no If yes, what portion is on microform (provide dates, case number, volumes, etc.) 7. Filing Arrangement: 1. alphabetic 3. numeric 5. other (specify) 2. chronologic 4. disarranged 8. Are these records indexed? yes no If yes, a. Will the index continue to be available in your office? yes no b. Are you offering the index to the State Hist. Society? yes no 9. Describe record if not included in items 1-60, SCR Chapter 72.01: Signature of State Archivist The State Historical Society accepts declines offer of these records. Comments: Date Date Record Transferred to State Historical Society Signature of Authorized Custodian