TD F 92-22.46 Request for Transfer of Property Seized/Forfeited by a T

DEPARTMENT OF THE TREASURY

OMB No. 1505-0152

Request for Transfer of Property Seized/Forfeited by a Treasury Forfeiture Fund Participating Agency
 All assets transferred must be used in accordance with the U.S. Department of Justice and U.S Department of the
Treasury Guide to Equitable Sharing for State, Local, and Tribal Law Enforcement Agencies.
 The deadline for submission of this request is forty-five (45) days following the forfeiture date of the asset
requested.
 The requesting agency will be responsible for reimbursing the Treasury Forfeiture Fund its costs.

I. Seizing Agency (For Treasury Fund Participating Agency Use Only)
Seizing Agency (Federal):
Seizure Number Forfeiture:
Date:
Field Office:
Federal Agency Case No.
Case Type:

Adoption

Joint

II. Requesting State or Local Agency
Requesting Agency:
NCIC/ORI Number:
Recipient Agency Fiduciary for:
Address:
City:
State:
Zip Code:
Contact Person:
Telephone Number:
Email Address:

Requesting Agency Case No.:

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Seizure Number: ____________________
III. Asset Requested (If requesting more than one asset, please attach a list)
Asset Requested : _________________________
Asset Description: _________________________
Request Type:

Cash Proceeds: _______

Item: _________________

IV. Recipient Agency Participation/Contribution
How many workhours were expended in the seizure/forfeiture of this asset? _________________
Will sharing be based on pre-determined percentage in a Task Force Agreement
that was applicable at the time of the seizure/forfeiture? Yes
No

If YES, please attach the Memorandum of Understanding/ Agreement.

Summary of Participation to the seizure and forfeiture of the referenced asset:
*****Summary should include information such as who initiated the investigation, did the
requesting agency provide POI/POE payments and the amount, were extraordinary
expenses incurred by the requesting agency (i.e., Pens/Ping orders, T-III, etc., and any
specific assistance (i.e., narcotics K-9, computer forensic assistance, SRT, etc.) that lead to
the seizure of the referenced asset*****

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Seizure Number: ___________________

V. Department of the Treasury Title VI Civil Rights Requirements
Language Assistance Plan – The recipients must develop a language plan to offer assistance to limited English
proficient beneficiaries as needed. – Existing Recipient Guidance Regarding Executive Order 13166,70 Fed. Reg.
6067 (February 4, 2005).
Does the Recipient Agency have a Language Assistance Plan? Yes
No
Location of Notice of Rights – Recipients are required to provide information to beneficiaries and participants of the
protection against discrimination.
Does the Recipient Agency have a Notice of Rights? Yes
No
Where is the Notice Posted? _________________________________

VI.

Certification by Participating/Fiduciary Agency

Is the agency authorized to submit a request for an equitable sharing of this asset under applicable State law?
Yes

A.

No

I certify that the above information including, but not limited to, the number of workhours and the
narrative contributions to the investigation, are true and accurate statements of this agency’s
activities. I further certify that the funds or property transferred will be used only for permissible law
enforcement purposes, all funds received will be accounted for, and their use reported annually in
accordance with the Department of Justice and the Department of the Treasury policies on Equitable
Sharing. Falsified information on this form, failure to expend sharing funds permissibly, or failure to
accurately report expenditures could result in the agency’s suspension or expulsion from the
Equitable Sharing Program.

Name: ______________________________________

Title:______________________________________

Signature: _____________________________________

Date: _____________________________________

B.

As legal counsel, I have reviewed this request and I certify that the contact person identified
in Part II, on behalf of the agency referenced in Part II, has the authority to accept seized/forfeited property
and is the official to whom transfer documents and/or money should be delivered. I further certify that the
agency referenced in Part II is authorized to request and receive equitable sharing.

Name: ______________________________________

Title:______________________________________

Signature: _____________________________________

Date: _____________________________________

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