6._17-R-0005_Request_for_Documents_-_DAForm3964-Classified_Document_Accountability_Record.pdf

PRINTED NAME SIGNATURE

1.

2.

3.

4.

5.

OFFICE SYMBOL

DESTRUCTION RECORD NO.

PAGE OR COPY NUMBER

DATE

DATE

DATE

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 ACCOUNTABILITY RECORD

For use of this form, see AR 380-5; the proponent agency is the Office, Assistant Chief of Staff for Intelligence.

DA FORM 3964, JUL 1979 APD LC V2.00PD PE v2.00

SECTION A - GENERAL

ACTION OFFICE(S) SUSPENSE DATE(S)

CONTROL LOG

OR FILE NO.

CLASSIFI-

CATION

NUMBER

OF COPIES

DESCRIPTION (Type, File Ref., Unclassified Subject or Short Title and Number of Indorsements/Incls)

DATE OF

DOCUMENT ORIGINATOR

SECTION B - ROUTING

TO COPY NO. DATE

I ACKNOWLEDGE RECEIPT OF THE MATERIAL DESCRIBED HEREON

SECTION C - DESTRUCTION CERTIFICATE (Check appropriate block)

MATERIAL DESCRIBED HEREON HAS BEEN:

DESTROYED TORN IN HALF AND PLACED IN A CLASSIFIED WASTE CONTAINER

(AR 380-5)

SECTION E - RECEIPT/TRACER ACTION (Check appropriate block)

RECEIPT OF DOCUMENT(S) ACKNOWLEDGED DOCUMENT(S) HAVE NOT BEEN RECEIVED

TRACER ACTION: SIGNED RECEIPT FOR MATERIAL DESCRIBED ABOVE HAS NOT BEEN RECEIVED.

SECTION D - REPRODUCTION AUTHORITY

EDITION OF 1 NOV 72 IS OBSOLETE.

DESTROYED TORN IN HALF AND PLACED IN A CLASSIFIED WASTE CONTAINER (AR 380-5)

PRINTED NAME

SIGNATURE

1.

2.

3.

4.

5.

OFFICE SYMBOL

DESTRUCTION RECORD NO.

PAGE OR COPY NUMBER

DATE

DATE

DATE

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 ACCOUNTABILITY RECORD

For use of this form, see AR 380-5; the proponent agency is the Office, Assistant Chief of Staff for Intelligence.

DA FORM 3964, JUL 1979

APD LC V2.00

PD PE v2.00

SECTION A - GENERAL

ACTION OFFICE(S)

SUSPENSE DATE(S)

CONTROL LOG OR FILE NO.

CLASSIFI- CATION

NUMBEROF COPIES

DESCRIPTION (Type, File Ref., Unclassified Subjector Short Title and Number of Indorsements/Incls)

DATE OF DOCUMENT

ORIGINATOR

SECTION B - ROUTING

TO

COPY NO.

DATE

I ACKNOWLEDGE RECEIPT OF THE MATERIAL DESCRIBED HEREON

SECTION C - DESTRUCTION CERTIFICATE (Check appropriate block)

MATERIAL DESCRIBED HEREON HAS BEEN:

DESTROYED

TORN IN HALF AND PLACED IN A CLASSIFIED WASTE CONTAINER

(AR 380-5)

SECTION E - RECEIPT/TRACER ACTION (Check appropriate block)

RECEIPT OF DOCUMENT(S) ACKNOWLEDGED

DOCUMENT(S) HAVE NOT BEEN RECEIVED

TRACER ACTION: SIGNED RECEIPT FOR MATERIAL DESCRIBED ABOVE HAS NOT BEEN RECEIVED.

SECTION D - REPRODUCTION AUTHORITY

EDITION OF 1 NOV 72 IS OBSOLETE.

DESTROYED

TORN IN HALF AND PLACED IN A CLASSIFIED WASTE CONTAINER (AR 380-5)

2.00

DA FORM 3964, JUL 1979

CLASSIFIED DOCUMENT ACCOUNTABILITY RECORD

APD

ATTN: WGS&P Terrain Analysis Branch (John C. Jens) 7701 Telegraph Road, Alexandria, VA 22315-3864

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