Form 41 Registrants Inventory of Drugs Surrendered

OMB Approval
No. 1117 - 0007

PACKAGE NO.

U. S. Department of Justice / Drug Enforcement Administration

REGISTRANTS INVENTORY OF DRUGS SURRENDERED

The following schedule is an inventory of controlled substances which is hereby surrendered to you
for proper disposition.
FROM: (Include Name, Street, City, State and ZIP Code in space provided below.)
Signature of applicant or authorized agent

Registrant’s DEA Number
Registrant’s Telephone Number

NOTE: CERTIFIED MAIL (Return Receipt Requested) IS REQUIRED FOR SHIPMENTS
OF DRUGS VIA U.S. POSTAL SERVICE. See instructions on reverse (page 2) of form.

NAME OF DRUG OR PREPARATION

Registrants will fill in Columns 1,2,3, and 4 ONLY.
1

CONTENTS ConNumber (Number of trolled
Subgrams,
of
stance
tablets,
ConConounces or
tent,
tainers other units
(Each
per conUnit)
tainer)
2

3

4

FOR DEA USE ONLY

DISPOSITION

QUANTITY
GMS.

5

MGS.

6

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
FORM DEA-41 (9-01)

Previous edition dated 6-86 is usable.

See instructions on reverse (page 2) of form.

7

DEA-41 (6/1986) Pg. 2

NAME OF DRUG OR PREPARATION

Registrants will fill in Columns 1,2,3, and 4 ONLY.
1

CONTENTS ConNumber (Number of trolled
grams,
Subof
tablets,
stance
Conounces or
Containers other units
tent,
per con(Each
tainer)
Unit)
2

3

4

FOR DEA USE ONLY
QUANTITY

DISPOSITION

GMS.

MGS.

6

7

5

17
18
19
20
21
22
23
24
The controlled substances surrendered in accordance with Title 21 of the Code of Federal Regulations, Section 1307.21, have been received
in _______packages purporting to contain the drugs listed on this inventory and have been: ** (1) Forwarded tape-sealed without opening;
(2) Destroyed as indicated and the remainder forwarded tape-sealed after verifying contents; (3) Forwarded tape-sealed after verifying contents.

DESTROYED BY:

DATE
** Strike out lines not applicable.

WITNESSED BY:

INSTRUCTIONS
1.

List the name of the drug in column 1, the number of containers in column 2, the size of each container in column 3, and in column 4 the
controlled substance content of each unit described in column 3; e.g., morphine sulfate tabs., 3 pkgs., 100 tabs., 1/4 gr. (16 mg.) or morphine
sulfate tabs., 1 pkg., 83 tabs., 1/2 gr. (32mg.), etc.

2.

All packages included on a single line should be identical in name, content and controlled substance strength.

3.

Prepare this form in quadruplicate. Mail two (2) copies of this form to the Special Agent in Charge, under separate cover. Enclose one additional
copy in the shipment with the drugs. Retain one copy for your records. One copy will be returned to you as a receipt. No further receipt will be
furnished to you unless specifically requested. Any further inquiries concerning these drugs should be addressed to the DEA District Office which
serves your area.

4.

There is no provision for payment for drugs surrendered. This is merely a service rendered to registrants enabling them to clear their stocks and
records of unwanted items.

5.

Drugs should be shipped tape-sealed via prepaid express or certified mail (return receipt requested) to Special Agent in Charge, Drug
Enforcement Administration, of the DEA District Office which serves your area.
PRIVACY ACT INFORMATION
AUTHORITY: Section 307 of the Controlled Substances Act of 1970 (PL 91-513).
PURPOSE: To document the surrender of controlled substances which have been forwarded by registrants to DEA for disposal.
ROUTINE USES: This form is required by Federal Regulations for the surrender of unwanted Controlled Substances. Disclosures
of information from this system are made to the following categories of users for the purposes stated.
A. Other Federal law enforcement and regulatory agencies for law enforcement and regulatory purposes.
B. State and local law enforcement and regulatory agencies for law enforcement and regulatory purposes.
EFFECT: Failure to document the surrender of unwanted Controlled Substances may result in prosecution for violation of the
Controlled Substances Act.
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a currently valid OMB
control number. Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing
this burden, to the Drug Enforcement Administration, FOI and Records Management Section, Washington, D.C. 20537; and to the Office of
Management and Budget, Paperwork Reduction Project no. 1117-0007, Washington, D.C. 20503.