"I certify pursuant to section 16.61(7) (c), Wis. Stats., that this record series has been photographed on the reel of film listed above." Or this statement may be omitted if a statement for each record series or schedule such as the following was filed before the filming started:
"I, (name), employed by (city or village), do hereby declare that the records microfilmed herein are the actual records of the (department or agency and record title) created during its normal course of business, and that:
It is the express intent and purpose of this organization: a. to destroy, orb. to otherwise dispose of the original records, orc. in the case of records microfilmed for security and purposes return records to (department or agency) and file security copy of the microfilm in a safe depository and that:
The destruction, disposition, or returning of the records microphotographed on this reel is only to be accomplished after inspection of the microfilm to assure completeness of coverage, and that:
It is the policy of this organization to microfilm and dispose or return original records as part of the planned organizational operating procedure."
Date_______________ 19________
(month)
(date)
(signature)
Place________________ ______
(city)
(state)
(title)
_____________
(department)
Wis. Admin. Code Public Records Board PR 1.02