Form ATF F 5400.5 ATF F 5400.5 Report of Theft or Loss-Explosive Materials

OMB No. 1140-0026 (01/31/2009)

U.S. Department of Justice
Bureau of Alcohol, Tobacco, Firearms and Explosives

Report of Theft or Loss-Explosive Materials

For ATF Use Only
Date Faxed to JSOC & Field Division

Unique Identifier
Case Number
To Be Completed By Person Making Report
Upon discovery of any theft or loss of any of your explosive materials:
- First, contact ATF toll free at 1-800-461-8841 between 8:00 a.m. - 5:00 p.m. EST or after-hours and weekends contact ATF at 1-800-800-3855
to report the theft or loss;
- Second, contact your local law enforcement office to report the theft or loss to obtain a police report; and
- Third, complete this form and attach any additional reports, sheets or invoices necessary to provide the required information, and fax the form with
additional material(s) to the ATF U.S. Bomb Data Center (USBDC) at 866-927-4570.

Date Received

1. Date:

2. Type of Report (Check one):

3. Full Name of Person Making Report (Last, First, Middle)

Theft

Loss

Supplement

4. Corporate or Business Name (If applicable)

5a. Office Address (Street Address, City, State, and Zip Code)

5b.Telephone Number

6. Actual Location of Theft or Loss (If different from item 5a)

Date

7. Theft or Loss

Time

a. Discovered

8. Name of Local Law Enforcement Officer to Whom Reported
9. Agency Name and Address of Local Authority to Whom Reported

b. Occurred (Show approximate
if exact not known)
c. Reported to ATF by Telephone

10. Telephone Number:

d. Reported to Local Authorities

11. Police Report Number:

12. Explosive Materials Lost or Stolen (attach invoices or additional sheets, if necessary)

a. Manufacturer

b. Brand Name

c. Date Shift
Code

13. Theft or Loss Occurred from (Check applicable box)
Portable
Permanent
Truck
Magazine
Magazine

d. Size

Work Site

f. Type and Description
e. Quantity
(Dynamite, Blasting Agents, Detonators,
(Pounds of Explosives, etc. Include for each type, size, MS delay or
Number of Dets)
length of legwire, as applicable)

Other (Explain)
ATF Form 5400.5
Revised March 2008

14. Method of Entry (Complete if applicable)
Locks Cut
Locks Picked
Door Unlocked
Door Blown
Open

Inside Help
Wall Entry
Key Stolen/
Used

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

Yes

No

Broken
Cut
Removed
Inadequate for Lock Used

16. Other information Pertinent to the Theft or Loss (Attach separate sheets if additional space is needed)

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. 8 S 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).
1. 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.
2. 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.
3. 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.
4. 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 Form 5400.5
Revised March 2008