CLASSIFIED DOCUMENT ACCOUNTABILITY RECORD - United …

1 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 1979 APD LC PE A - GENERALACTION OFFICE(S)SUSPENSE DATE(S)CONTROL LOG OR FILE CATIONNUMBER OF COPIESDESCRIPTION (Type, File Ref.)

2 , 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) ACKNOWLEDGEDDOCUMENT(S) HAVE NOT BEEN RECEIVEDTRACER ACTION: SIGNED RECEIPT FOR MATERIAL DESCRIBED ABOVE HAS NOT BEEN D - REPRODUCTION AUTHORITYEDITION OF 1 NOV 72 IS IN HALF AND PLACED IN A CLASSIFIED WASTE CONTAINER (AR 380-5)