Fill - Free fillable Limited Permittee Transaction Report (Bureau of Alcohol, Tobacco, Firearms, and Explosives) PDF form

ATF E-Form 5400.4

Revised May 2003

U.S. Department of Justice

Bureau of Alcohol, Tobacco, Firearms and Explosives

Limited Permittee Transaction Report

OMB No. 1140-0025

For ATF Use Only

Transaction Serial Number (Optional)

Affix ATF Form 5400.30, Interstate Purchase of Explosives

Coupon (IPEC) - Copy A

Section A - (Must be completed by the person purchasing the explosive materials)

1. PERSON USING THIS COUPON TO PURCHASE EXPLOSIVE MATERIALS: I declare under the penalties of perjury that I am either the limited permittee identified

below, a responsible person or an employee of the limited permittee authorized to received explosive materials on the limited permittee's behalf (name is listed on the list of

names provided by the limited permittee to receive explosive materials on their behalf.)

2. What is the intended use of the purchased explosive materials? (e.g., well drilling, beaver dam, model rocket, fireworks, drilling rock, blasting, construction, theatrics, etc.)

3. Under the penalties imposed by 18 U.S.C. 844, I certify that the answers are true, correct, and complete. I also certify that I am familiar with all published Federal, State law

and local ordinances related to explosive materials for the location in which I reside and intended to use these explosives.

Print Name of Distributee (buyer or authorized employee) Title: Date:

Distributer's (Buyer or authorized employee's) Signature:

Section B - (Must be completed by the Federally licensed explosive distributor or seller)

1. The distributee listed above purchased the following explosive materials with this Intrastate Purchase Explosive Coupon. (If additional space is required, use a separate

sheet.)

Quantity in

Pound/Units

Manufacturer's/Importer's

Name or Brand Name

Manufacturer's/Importer's Mark's

of Identification (optional)

Description

(e.g., Dynamite, detonators)

Size (optional)

2. The distribution of explosive materials was identified in the manner described below. (Check one)

a. The explosive materials were distributed by the distributor, or an employee of the distributor. (Complete item 2c-e and see instruction 12);

b. A common or contract carrier hired by the distributor delivered the explosive materials for the distributee and identification information on the distributee was

obtained by other means. (Complete item 2c-e and see interaction 13);

c. Distributee's Type of Identification (e.g., driver's license or other

valid government issued photo identification)

d. Number on identification: e. Expiration Date of identification

(if any)

f. A common or contract carrier hired by the distributee delivered the explosive materials to the distributor to the distributee. (Item 2c-e is not require to be completed.

See instruction 6.)

3. The above person is. (Check one)

a. The Person identified above in Section B, number 2 as the "Limited Permittee"

b. Listed as an employee authorized to receive explosive materials for the limited permittee. (NOTE: A current list of names of employees authorized to accept delivery

of explosive materials on behalf of the limited permittee must be on file.)

The explosive material were delivered to the limited permittee by contract or common carrier. (ATF Form 5400.8 must complete and attached.)

5. Distributor's Business Name and Address 6. Distributor's License Number

7. Distributor's Signature 8. Title 9. Transaction Date

Section C - (Must be completed by the individual (purchaser or purchaser's employee) receiving the explosive materials if the distribution of the explosive materials takes

place on a different day from the date the limited permittee signed in Section A)

1. Print name of person receiving the explosive materials:

2. Signature: 3. Date:

Original - ATF's Copy