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 :_________________________________________________

SAM/Unique Entity Identifier (UEI): ___________________EFT INDICATOR:______________

_{Recipient Agency Fiduciary for: ________TASKFORCE NAME}

Address :________________________________________________

City :________________________________________________

State

: __

Zip Code

Contact Person _{: _______________________________________________}

Telephone Number : _________________________________________________

^{Email Address :}

Requesting Agency Case No. : ______________________________________________________

Seizure Number: ____________________

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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 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*****

Summary of Participation to the seizure and forfeiture of the referenced asset:

Seizure Number: ___________________

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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 No

1. 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: __________________________________}

2. 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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TD F 92-22.46 (4/2024) PREVIOUS VERSIONS OBSOLETE