ATF Form 5400.4 Limited Permittee Transaction Report

ATF Form 5400.4 is a U.S. Department of Justice - Bureau of Alcohol, Tobacco, Firearms and Explosives form also known as the "Limited Permittee Transaction Report". The latest edition of the form was released in May 1, 2003 and is available for digital filing.

Download an up-to-date ATF Form 5400.4 in PDF-format down below or look it up on the U.S. Department of Justice - Bureau of Alcohol, Tobacco, Firearms and Explosives Forms website.

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U.S. Department of Justice
OMB No. 1140-0025
Bureau of Alcohol, Tobacco, Firearms and Explosives
Limited Permittee Transaction Report
For ATF Use Only
Affix ATF Form 5400.30, Interstate Purchase of Explosives
Coupon (IPEC) - Copy A
Transaction Serial Number (Optional)
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
Manufacturer's/Importer's
Manufacturer's/Importer's Mark's
Description
Size (optional)
Pound/Units
Name or Brand Name
of Identification (optional)
(e.g., Dynamite, detonators)
a.
b.
c.
d.
e.
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);
or
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
d. Number on identification:
e. Expiration Date of identification
valid government issued photo 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.)
4.
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:
ATF E-Form 5400.4
Original - ATF's Copy
Revised May 2003
U.S. Department of Justice
OMB No. 1140-0025
Bureau of Alcohol, Tobacco, Firearms and Explosives
Limited Permittee Transaction Report
For ATF Use Only
Affix ATF Form 5400.30, Interstate Purchase of Explosives
Coupon (IPEC) - Copy A
Transaction Serial Number (Optional)
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
Manufacturer's/Importer's
Manufacturer's/Importer's Mark's
Description
Size (optional)
Pound/Units
Name or Brand Name
of Identification (optional)
(e.g., Dynamite, detonators)
a.
b.
c.
d.
e.
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);
or
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
d. Number on identification:
e. Expiration Date of identification
valid government issued photo 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.)
4.
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:
ATF E-Form 5400.4
Original - ATF's Copy
Revised May 2003
U.S. Department of Justice
OMB No. 1140-0025
Bureau of Alcohol, Tobacco, Firearms and Explosives
Limited Permittee Transaction Report
For ATF Use Only
Affix ATF Form 5400.30, Interstate Purchase of Explosives
Coupon (IPEC) - Copy A
Transaction Serial Number (Optional)
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
Manufacturer's/Importer's
Manufacturer's/Importer's Mark's
Description
Size (optional)
Pound/Units
Name or Brand Name
of Identification (optional)
(e.g., Dynamite, detonators)
a.
b.
c.
d.
e.
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);
or
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
d. Number on identification:
e. Expiration Date of identification
valid government issued photo 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.)
4.
The explosive material were delivered to the limited permittee by contract or common carrier. (ATF Form 5400.8 must be 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:
ATF E-Form 5400.4
Licensee's Copy
Revised May 2003
Instructions
information on Section B of ATF Form 5400.4. ATF Form 5400.8 must be
attached to the distributor's copy of the ATF Form 5400.4 and retained in his
1. THIS FORM IS TO BE UTILIZED ON AND AFTER MAY 24, 2003. ATF FORM
permanent records in accordance with 27 CFR 555.121.
5400.4, TITLE EXPLOSIVES TRANSACTION RECORD, DATED 12-2002 IS
OBSOLETE AS OF MAY 24, 2003 AND CANNOT BE USED
14. Identification of a person accepting possession of explosive materials may be
verified by presenting a valid driver's license or State-issued identification
2. All signatures on this form must be in ink and all other entries must be in ink or
card. The identification document should establish a person's name, date of
typewritten.
birth, signature, photograph and State of residence.
3. This form must be prepared for each transaction involving distribution of explosive
15. If the distribution of the explosive materials takes place on a different day
materials to persons who have been issued a Federal explosives limited permit.
from the date on which the limited permittee, or employee, signed in Section
Distributee - (Purchaser)
A, the licensee must again check the photo identification of the person
receiving the explosive materials, and the person receiving the explosive
4. Prior to receipt of explosive materials, the limited permittee must complete Section A
materials must complete the certification in Section C at the time of
of ATF Form 5400.4 and affix one of his six original Intrastate Purchase of
distribution of the explosive materials.
Explosives Coupon(s) (IPEC), ATF F 5400.30, onto copies 1 and 2 of ATF Form
5400.4. The coupon must bear the name, address, permit number, and the coupon
16. The seller should contact the local ATF field office to report suspicious
number.
coupons or suspicious attempts to purchase explosives.
5. A licensed importer, licensed manufacturer or a licensed dealer may distribute
Definitions
explosive materials to a holder of a limited permit if such permittee is a resident of
the same State in which the licensee's premises are located.
1. 6 Separate Occasions - Six receipts of explosive materials and each receipt must
6. Delivery by common or contract carrier hired by the distributee: Where a common or
(1) relate to a single purchase transaction made on one ATF Form 5400.4; (2)
contract carrier will transport explosive materials from the distributor to a holder of a
be referenced on one commercial invoice or purchase order; and (3) be
limited permit, the limited permittee will, prior to delivery of the explosive materials,
delivered to the holder of the limited permit in one shipment delivered at the
complete Section A on ATF Form 5400.4, affix to the form one of the six IPECs he
same time.
has been issued, and provide the form to the distributor in person or by mail. Before
the delivery of explosive materials from the distributor's premises to the common or
2. Limited Permit - A limited permit authorizes the holder to receive for his use
contract carrier, the distributor must obtain an executed ATF Form 5400.8,
explosive materials from a licensee or permittee in his State of residence on no
Explosives Delivery Record, from the common or contract carrier before releasing
more than 6 occasions during the 12-month period in which the permit is valid.
the explosive materials. ATF Form 5400.8 must contain all of the information
A limited permit does not authorize the receipt or transportation of explosive
required by that form and by this part. ATF Form 5400.8 must be attached to the
materials in Interstate or foreign commerce.
distributor's copy of the ATF Form 5400.4 and retained in his permanent records in
accordance with 27 CFR 555.121.
Privacy Act Information
7. If the distribution of the explosive materials takes place on a different day from the
The following information is provided pursuant to Section 3 of the Privacy Act of
date on which the limited permittee, or employee, signed in Section A, then the
1974 [5 U.S.C. Section 552a(3)]:
person receiving the explosive materials must complete Section C.
8. When any Intrastate Purchase of Explosives Coupon (IPEC), ATF Form 5400.30, is
1. Authority. Solicitation of this information is made pursuant to 18 U.S.C.
stolen, lost, or destroyed, the person losing possession will, upon discovery of the
Sections 842 and 843. Disclosure of this information is mandatory.
theft, loss or destruction, immediately, but in all cases before 24 hours have elapsed
since the discovery, report the matter to the Director by telephoning 1-888-ATF-
2. Purpose. To identify the permittee, distributor, and the explosive materials.
BOMB.
Distributor - (Seller)
3. Routine Uses. The information will be used by ATF to make determinations
set forth in paragraph 2. In addition, the information may be disclosed to other
9. The distributor (seller) of explosive materials, will in every instance, require the
Federal, State, foreign and local law enforcement and regulatory agency
limited permittee to complete all items in Section A prior to receipt of explosive
personnel to verify information on the form and to aid in the performance of
materials by the purchaser.
their duties with respect to the regulations of explosives, unless such disclosure
is prohibited by law. Finally, the information may be disclosed to members of
10. The seller will complete Section B and retain one copy of the form as record of
the public in order to verify the information on the form where such disclosure
disposition for the required record retention period in accordance with 27 CFR
is not prohibited by law.
555.121.
11. The seller will submit the original copy of ATF Form 5400.4 to ATF Firearms and
Paperwork Reduction Act Notice
Explosives Licensing Center, 244 Needy Road Martinsburg, WV 25405.
12. Where possession of explosive materials is transferred directly to the distributee at
This request is in accordance with the Paperwork Reduction Act of 1995. The
the seller's premises, the seller must obtain an executed ATF form 5400.4 and verify
purpose of this information collection is to verify that all persons who are
the identity of the person accepting possession of the explosive materials. In
purchasing explosive materials have the proper Federal permit and to ensure that
instances where an employee truck driver of the distributor delivers the explosive
such person have appropriate facilities for storage of the explosive materials. The
materials to the premises of the purchaser, the distributor's employee truck driver
information is subject to inspection by ATF officials. This information request is
will check item 2A, Section B.
mandatory by statute. (18 U.S.C. Sections 842 and 843.)
13. Delivery by common or contract carrier hired by the distributor: Where a common
The estimated average burden associated with this collection is 20 minutes per
or contract carrier will transport explosive materials from the distributor to a holder
respondent or recordkeeper, depending on individual circumstances. Comments
of a limited permit, the limited permittee will, prior to delivery of the explosive
concerning the accuracy of this burden estimate and suggestions for reducing this
materials complete Section A on ATF Form 5400.4, affix to the form one of the six
burden should be addressed to Reports Management Officer, Document Services
IPECs previously issued, and provide the form to the distributor in person or by
Branch, Bureau of Alcohol, Tobacco, Firearms and Explosives, Washington, DC
mail. Before the delivery of explosive materials from the distributor's premises to
20226.
the common or contract carrier who will transport explosive materials to the limited
permittee, the distributor must obtain an executed ATF Form 5400.8. Explosives
Delivery Record, from the common or contract carrier before releasing the
An agency may not conduct or sponsor, and a person is not required to respond to,
explosive materials. ATF Form 5400.8 must contain all of the information required
a collection of information unless it displays a currently valid OMB control
on the form by this part. At the time of delivery the common or contract carrier, as
number.
agent for the distributor, must verify the identity of the person accepting delivery on
behalf of the distributee, note the type and number of the identification document
and provide this information to the distributor. The distributor will enter this
ATF E-Form 5400.4
Revised May 2003

Download ATF Form 5400.4 Limited Permittee Transaction Report

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