Fillable Printable Classified Document Accountability Record
Fillable Printable Classified Document Accountability Record
Classified Document Accountability Record
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EDITION OF 1 NOV 72 IS OBSOLETE.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)
