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

OMB No. 1140-0026 (09/30/2016)

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 E-Mailed to JSOC & Field Division

BATS ID
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)

Theft

Loss

Attempted Theft/Suspicious
Activity

Supplement

4a. Licensee or Permittee Name

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
a. Discovered

Date

Time

8. Name of Local Law Enforcement Officer to Whom Reported
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
e. Reported to Local
Authorities

10. Telephone Number

11. Police Report Number

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

ATF E-Form 5400.5
Revised September 2014

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

2

2 Det. Box

3 Day Box

Outdoor

Indoor

Permanent

Portable

Overnight Storage

Day Storage

4

5

Mobile Truck

Mobile Trailer

Mortise

3-Point

Puck Lock

Other (Explain)

Remote Storage

Work Site

In Transit

During Operations

b. Types of Locks (Check all that apply):
Padlock
c. Location Description/Type:
Licensed/Permitted
Premises
14. Method of Entry:
Door

Was a Key Used?

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?
Yes

Employee

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. Circumstances Pertaining 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

Lightning

Other (Explain)
18. Date

ATF E-Form 5400.5
Revised September 2014

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.
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 E-Form 5400.5
Revised September 2014