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

OMB No. 1140-0026 (xx/xx/xxxx)

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

Date Received

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 or email to USBDC@atf.gov.
1. Date

2. Type of Report (Check one):

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

Attempted Theft/Suspicious
Activity
4a. Licensee or Permittee Name
Theft

Loss

Supplement

4b. Federal Explosives License or Permit Number
5a. Office Address (Street Address, City, State, and Zip Code)

5b. Telephone Number
5c. E-mail Address

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

7. Theft or Loss

Date

Time

8. Name of Local Law Enforcement Officer to Whom Reported

a. Discovered
9. Name and Address of Local Authority to Whom Reported
b. When Was the Magazine Last
Checked
c. Occurred (Show approximate
if exact not known)
d. Reported to ATF by
Telephone

10. Telephone Number

e. Reported to Local
Authorities

11. Police Report Number

12. Explosive Materials Lost or Stolen (Attach invoices or additional sheets, if necessary)
e. Quantity
d. Size
c. Date Shift
a. Manufacturer and/or
f. Type and Description
b. Brand Name
(Length & Diameter) (Pounds of Explosives, (Dynamite, Blasting Agents, DetonaCode
Importer
Number of Dets)
tors, etc. Include for each type, size, MS
delay or length of legwire, as applicable)

ATF Form 5400.5
Revised (
)

13. Theft or Loss Occurred from (Check applicable box on each row)
a. Magazine Type:
1

2

Outdoor

Indoor

Permanent

Portable

Overnight Storage

Day Storage

2 Det. Box

3 Day Box

Mobile Truck

Mobile Trailer

5

4

b. Types of Locks (Check all that apply):
Padlock

Mortise

3-Point

Puck Lock

Other (Explain)

Remote Storage

Work Site

In Transit

During Operations

c. Location Description/Type:
Licensed/Permitted
Premises
14. Method of Entry:
Was a Key Used?

Door
Wall(s)

Roof

Yes

No

Suspected Employee-Involved
Theft?
Yes
No

Floor/Bottom

Lock(s) Defeated? (If yes, check additional appropriate boxes)

Yes

No

Lock Shackle Cut (How?)

Lock Pried, Twisted or Levered

Lock Left Unlocked

Lock Picked or Shimmed

Keyway Drilled Out

Lock Body Drilled Out or Cut

Other (Explain)
Manufacturer and Model of Lock:

Location of Magazine Keys:

Office

Are All Keys Accounted For?

Employee

Yes
Other (Address)
15. Hood Defeated? (If yes, check all applicable)

Yes

No
No

Hood Cut

Hood Removed

Other (Explain)

Hood Broken

Hood Width (Inches)

Hood Length (Inches)

Hood Depth (Inches)

Hood Thickness (Inches)

16. Other Information Pertinent to the Theft, Loss or Suspicious Activity (Any details you can provide)

16a. Was Theft or Loss Disclosed During an ATF Inspection or Being Reported as a Result of Inspection?

Yes

No

16b. Additional Security Measures in Place?
Alarm

Security System/Service

17. Signature and Title of Person Making Report

Fencing

Lighting

Other (Explain)
18. Date

ATF Form 5400.5
Revised (
)

Reporting Instructions
Email or 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
Email Address: USBDC@atf.gov
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. System of records notice Justice/ATF-008 Regulatory Enforcement Record System FR Vol.68 No.16 Page 3558 dated
January 24, 2003.
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, 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 (
)