Atf E-Form 5400.5 - Report Of Theft Or Loss - Explosive Materials Page 2

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14. Method of Entry (Complete if applicable)

15. Hood Defeated (If yes, check the applicable box below) Yes

Locks Cut

Inside Help

Broken

Locks Picked

Wall Entry

Cut

Key Stolen/

Door Unlocked

Removed

Used

Door Blown

Inadequate for Lock Used

Open

16. Other Information Pertinent to the Theft or Loss

17. Signature and Title of Person Making Report

Date

18. Federal Explosives License or Permit Number

Reporting Instructions

Fax this completed form to the ATF address listed below or call if no fax is available:

Bureau of Alcohol, Tobacco, Firearms and Explosives

U.S. Bomb Data Center

99 New york Ave., N.E. 8S 295

Washington, DC 20226

Toll Free Fax: 1-866-927-4570

Questions regarding the completion of this form should be referred to the U.S. Bomb Data Center toll free at 1-800-461-8841.

Privacy Act Information

The following information is provided pursuant to section 3 of the Privacy Act of 1974 (5 U.S.C. § 522a(e)(3))

Authority. Solicitation of this information is made pursuant to Title XI of the Organized Crime Control Act of 1970 (18 U.S.C. Chapter 40).

Disclosure of a theft or loss of explosive materials is mandatory pursuant to 18 U.S.C. § 842(k) for any person who has knowledge of such theft or loss

from his stock.

Purpose. The purpose for the collection of this information is to give ATF notice of the theft or loss of explosive materials, and to furnish ATF with

the pertinent facts surrounding such theft or loss. In addition, the information is used to confirm and verify prior notification of this theft or loss of

explosive materials.

Routine Uses. The information will be used by ATF to aid in the administration of laws within its jurisdiction concerning the regulation of explosive

materials and other related areas. In addition, the information may be disclosed to other Federal, State, foreign, and local law enforcement of laws

within their jurisdiction.

Effects of not supplying information requested. 18 U.S.C. § 842(k) makes it unlawful for any person, who has knowledge of the theft or loss of

explosive materials from his stock, to fail to report such theft or loss within twenty-four hours of discovery thereof, to the Secretary and to appropriate

local authorities. The penalty for violation of this section is a fine of not more than $1,000 or imprisonment for not more than one year, or both. 18

U.S.C. § 844(b)

Paperwork Reduction Act Notice

This request in accordance with the Paperwork Reduction Act of 1995. The purpose of this information collection is to report the theft or loss of explosive

materials. The information is used for investigative purposes by ATF officials. This information is mandatory by statute. (18 U.S.C. § 842)

The estimated average burden associated with this collection of information is 1 hour and 48 minutes per respondent or recordkeeper, depending on

individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be addressed to

Reports Management Officer, Document Services Branch, Bureau of Alcohol, Tobacco, Firearms and Explosives, Washington, DC 20226.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB

control number.

ATF E-Form 5400.5

Revised March 2008