CLASSIFIED DOCUMENT ACCOUNTABILITY RECORD

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PRINTED SYMBOLDESTRUCTION RECORD OR COPY NUMBERDATEDATEDATEPRINTED NAME OF custodian OR REPPRINTED NAME OF CERTIFYING/DESTR. NAME OF WITNESSING OFFICIALSIGNATURESIGNATURESIGNATURETO: COMMENTSDATEPRINTED NAME, GRADE OR TITLESIGNATUREDATEFROM: DATE RECEIVEDREGISTER OR CONTROL OR COPY NONUMBER OR COPIES TO BE REPRODUCEDAUTHORIZED BYDATECLASSIFIED DOCUMENT ACCOUNTABILITY RECORDFor use of this form, see AR 380-5; Proponent agency is the Office of the Deputy Chief of Staff, FORM 3964, JUL 1979APD LC PE A - GENERALACTION OFFICE(S)SUSPENSE DATE(S)CONTROL LOG OR FILE CATIONNUMBER OF COPIESDESCRIPTION (Type, File Ref., Unclassified Subject or Short Title and Number of Indorsements/Incls)DATE OF DOCUMENTORIGINATORSECTION B - ROUTINGTOCOPY ACKNOWLEDGE RECEIPT OF THE MATERIAL DESCRIBED HEREONSECTION C - DESTRUCTION CERTIFICATE (Check appropriate block)MATERIAL DESCRIBED HEREON HAS BEEN:DESTROYEDTORN IN HALF AND PLACED IN A CLASSIFIED WASTE CONTAINER (AR 380-5)SECTION E - RECEIPT/TRACER ACTION (Check appropriate block)RECEIPT OF DOCUMENT (S) ACKNOWLEDG

printed name of custodian or rep printed name of certifying/destr. off. printed name of witnessing official signature. signature signature. to: comments. date printed name, grade or title. signature date. from: date received. register or control no. page or copy no. number or copies to be reproduced authorized by. date. classified document ...

  Document, Custodian