Form 41 Registrants Inventory of Drugs Surrendered

OMB APPROVAL NO. 1117-0007

Expiration Date MM/DD/YYYY

U. S. DEPARTMENT OF JUSTICE – DRUG ENFORCEMENT ADMINISTRATION

REGISTRANT RECORD OF CONTROLLED SUBSTANCES DESTROYED
FORM DEA-41

A. REGISTRANT INFORMATION
Registered Name:

DEA Registration Number:

Registered Address:
City:

State:

Zip Code:

Telephone Number:

Contact Name:

B. ITEM DESTROYED

Examples

1. Collection Disposal
Mail Back
Package

Inner
Liner

X
X

Unique Identification Number

Size of Inner Liner

MBP1106

N/A

CRL1007

15 gallon

1.
2.
3.
4.
5.
6.
7.

Examples

2. Registrant Disposal
National Drug
Code or
DEA Controlled
Substances Code
Number

Batch
Number

Name of Substance

Strength

Form

Pkg.
Qty.

Number
of Full
Pkgs.

Partial
Pkg.
Count

Total
Destroyed

16590-598-60

N/A

Kadian

60mg

Capsules

60

2

0

120 Capsules

0555-0767-02

N/A

Adderall

5mg

Tablet

100

0

83

83 Tablets

9050

B02120312

Codeine

N/A

Bulk

1.25 kg

N/A

N/A

1.25 kg

1.
2.
3.
4.
5.
6.
7.
Form DEA-41

See instructions on reverse (page 2) of form.

DEA-41 Pg. 2

C. METHOD OF DESTRUCTION
Date of Destruction:

Method of Destruction:

Location or Business Name:
Address:
City:

State:

Zip Code:

D. WITNESSES
I declare under penalty of perjury, pursuant to 18 U.S.C. 1001, that I personally witnessed the destruction of the abovedescribed controlled substances to a non-retrievable state and that all of the above is true and correct.
Printed name of first authorized employee witness:

Signature of first witness:

Date:

Printed name of second authorized employee witness:

Signature of second witness:

Date:

E. INSTRUCTIONS
1.

2.

3.

4.
5.

6.

7.

Section A. REGISTRANT INFORMATION: The registrant destroying the controlled substance(s) shall provide their DEA registration
number and the name and address indicated on their valid DEA registration, in addition to a current telephone number and a contact
name, if different from the name on the valid DEA registration.
Section B. (1) Collection Disposal: This part shall be used by registrants destroying controlled substances obtained through an
authorized collection activity in accordance with 21 U.S.C. 822(g). In each row, indicate whether registrant is destroying a mail back
package or an inner liner. If destroying a mail back package, enter the unique identification number on that package. If destroying
an inner liner, enter the unique identification number on such liner and in the subsequent column, the size of the liner destroyed. In
the case of mail back packages or inner liners received from a law enforcement agency which do not have a unique identification
number or clearly marked size, include the name of the law enforcement agency and, if known, the size of the inner liner or package.
DO NOT OPEN ANY MAIL BACK PACKAGE OR INNER LINER; AN INVENTORY OF THE CONTENTS OF THE PACKAGES OR
LINERS IS PROHIBITED BY LAW AND IS NOT REQUIRED BY THIS FORM.
Section B. (2) Registrant Disposal: This part shall be used by registrants destroying lawfully possessed controlled substances, other
than those described in Section B(1). In each row, indicate the National Drug Code (NDC) for the controlled substance destroyed, or
if the substance has no NDC, indicate the DEA Controlled Substances Code Number for the substance; if the substance destroyed is
in bulk form, indicate the batch number, if available. In each row, indicate the name, strength, and form of the controlled substance
destroyed, and the number of capsules, tablets, etc., that are in a full package (pkg. qty.). If destroying the full quantity of the
controlled substance, indicate the number of packages destroyed (number of full pkgs.). If destroying a partial package, indicate the
partial count of the capsules, tablets, etc. destroyed (partial pkg. count). If destroying a controlled substance in bulk form, indicate
that the substance is in bulk form (form) and the weight of the substance destroyed (pkg. qty.). In each row, indicate the total number
of each controlled substance destroyed (total destroyed).
If additional space is needed for items destroyed in Section B, attach to this form additional page(s) containing the requested
information for each controlled substance destroyed.
Section C. METHOD OF DESTRUCTION: Provide the date, location, and method of destruction. The method of destruction must
render the controlled substance to a state of non-retrievable and meet all applicable destruction requirements in accordance with 21
CFR part 1317.
Section D. WITNESSES: Two authorized employees employed full time by the registrant must declare by signature, under penalty
of perjury, that such employees personally witnessed the destruction of the controlled substances listed in Section B in the manner
described in Section C.
You are not required to submit this form to DEA, unless requested to do so. This form must be kept as a record of destruction and be
available by the registrant for at least two years in accordance with 21 U.S.C. 827.
Paperwork Reduction Act Statement: The information collected on this form is necessary for DEA registrants to record controlled
substances destroyed in accordance with the Controlled Substances Act (CSA). The records that DEA registrants maintain in
accordance with the CSA must be kept and be available, for at least two years, for inspection and copying by officers or employees of
the United States authorized by the Attorney General. 21 U.S.C. 827. DEA estimates that it will take approximately 30 minutes to
complete this form, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. The completion of this form by DEA registrants that destroy
controlled substances is mandatory in accordance with 21 U.S.C. 827. Please note that 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. Comments
regarding this information collection, including suggestions for reducing the burden estimate, should be directed to the Drug
Enforcement Administration, DEA Federal Register Representative/ODL, 8701 Morrissette Drive, Springfield, Virginia 22152.