Form OMB 1140-0025 (ATF OMB 1140-0025 (ATF Limited Permittee Transaction Report

Limited Permittee Transaction Report

F 5400. 4 (May 2003) with watermark

Limited Permittee Transaction Record

OMB: 1140-0025

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OMB No. 1140-0025

U.S. Department of Justice
Bureau of Alcohol, Tobacco, Firearms and Explosives

Limited Permittee Transaction Report
For ATF Use Only

Affix ATF Form 5400.30, Intrastate 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 receive 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 laws and local ordinances related to explosive materials for the location in which I reside and intend to use these explosives.
Print Name of Distributee (Buyer or authorized employee)

Title:

Date:

Distributee’s (Buyer’s or authorized employee’s) Signature:

Section B - (Must be completed by the Federally licensed explosives 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.)
Manufacturer’s/Importer’s
Description
Manufacturer’s/Importer’s Marks
Quantity in
Size (optional)
Name or Brand Name
(e.g., Dynamite, detonators)
of Identification (mandatory)
Pound/Units
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 to the distributee and identification information on
the distributee was obtained by other means. (Complete item 2c-e and see instruction 13);
c. Distributee’s Type of Identification (e.g., driver’s license
d. Number on Identification:
e. Expiration Date of
or other valid government issued photo identification)
Identification (if any)
f.

A common or contract carrier hired by the distributee delivered the explosive materials from distributor to the distributee. (Item 2c-e is
not required to be completed. See instruction 6.)
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 materials were delivered to the limited permittee by contract or common carrier. (ATF Form 5400.8 must completed and attached.)

5. Distributor’s Business Name and Address
7. Distributor’s Signature

6. Distributor’s License Number
9. Transaction Date

8. Title

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

ATF Form 5400.4
Revised May 2003

OMB No. 1140-0025

U.S. Department of Justice
Bureau of Alcohol, Tobacco, Firearms and Explosives

Limited Permittee Transaction Report
For ATF Use Only

Affix ATF Form 5400.30, Intrastate Purchase of
Explosives Coupon (IPEC) - Copy B

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 receive explosive materials on the
limited permittee’s behalf (name is listed on the list of names provided by the limited permittee to purchase 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 laws and local ordinances related to explosive materials for the location in which I reside and intend to use these explosives.
Print Name of Distributee (Buyer or authorized employee)

Title:

Date:

Distributee’s (Buyer’s or authorized employee’s) Signature:

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

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 to the distributee and identification information on
the distributee was obtained by other means. (Complete item 2c-e and see instruction 13);
e. Expiration Date of
c. Distributee’s Type of Identification (e.g., driver’s license d. Number on Identification:
Identification (if any)
or other valid government issued photo identification)

f. A common or contract carrier hired by the distributee delivered the explosive materials from distributor to the distributee. (Item 2c-e is
not required to be completed. See instruction 6.)
The above person is: (Check one)
a. The person identified above in Section B, number 2 as the “Limited Permittee.”

5. Distributor’s Business Name and Address
7. Distributor’s Signature

6. Distributor’s License Number
9. Transaction Date

8. Title

2. Signature:

3. Date:

Licensee’s Copy

ATF Form 5400.4
Revised May 2003

Instructions
THIS FORM IS TO BE UTILIZED ON AND AFTER MAY 24, 2003.
ATF FORM 5400.4, TITLE EXPLOSIVES TRANSACTION
RECORD, DATED 12-2002 IS OBSOLETE AS OF MAY 24, 2003,
AND CANNOT BE USED.

All signatures on this form must be in ink and all other entries must
be in ink or typewritten.

This form must be prepared for each transaction involving distribution of explosive materials to persons who have been issued a
Federal explosives limited permit.
Distributee - (Purchaser)

Prior to receipt of explosive materials, the limited permittee must
complete Section A of ATF Form 5400.4 and affix one of his
six original Intrastate Purchase of 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 number.
A licensed importer, licensed manufacturer or a licensed dealer
may distribute 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.

Delivery by common or contract carrier hired by the distributee:
Where a common or contract carrier will transport explosive
materials from the distributor to a holder of a limited permit, the
limited permittee will, prior to delivery of the explosive materials,
complete Section A on ATF Form 5400.4, affix to the form one of
the six IPECs he 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 contract
carrier, the distributor must obtain an executed ATF Form 5400.8,
Explosives Delivery Record, from the common or contract carrier
before releasing the explosive materials. ATF Form 5400.8 must
contain all of the information required by that form and by this part.
ATF Form 5400.8 must be attached to the distributor’s copy of the
ATF Form 5400.4 and retained in his permanent records in
accordance with 27 CFR 555.121.
If the distribution of the explosive materials takes place on a
different day from the date on which the limited permittee, or
employee, signed in Section A, then the person receiving the
explosive materials must complete Section C.

8. When any Intrastate Purchase of Explosives Coupon (IPEC), ATF
Form 5400.30, is stolen, lost, or destroyed, the person losing
possession will, upon discovery of the 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-BOMB.
Distributor - (Seller)

14. Identification of a person accepting possession of explosive
materials may be verified by presenting a valid driver’s license or
State-issued identification card. The identification document
should establish a person’s name, date of birth, signature, photograph and State of residence.
15. If the distrbution of the explosive materials takes place on a
different day from the date on which the limited permittee, or
employee, signed in Section A, the licensee must again check the
photo identification of the person receiving the explosive materials,
and the person receiving the explosive materials must complete
the certification in Section C at the time of distribution of the
explosive materials.
16. The seller should contact the local ATF field office to report suspicious coupons or suspicious attempts to purchase explosives.
Definitions
1.

6 Separate Occasions - Six receipts of explosive materials and
each receipt must (1) relate to a single purchase transaction made
on one ATF Form 5400.4; (2) be referenced on one commercial
invoice or purchase order; and (3) be delivered to the holder of the
limited permit in one shipment delivered at the same time.

Limited Permit - A limited permit authorizes the holder to receive
for his use explosive materials from a licensee or permittee in his
State of residence on no more than 6 occasions during the 12month period in which the permit is valid. A limited permit does not
authorize the receipt or transportation of explosive materials in
Interstate or foreign commerce.

5400.8, Explosives Delivery Record, from the common or contract
carrier before releasing the explosive materials. ATF Form 5400.8
must contain all of the information required on the form by this part.
At the time of delivery the common or contract carrier, as 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 identifcation document and provide this information to the
distributor. The distributor will enter this 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 permanent records in accordance with 27 CFR 555.121.

The distributor (seller) of explosive materials, will, in every
instance, require the limited permittee to complete all items in
Section A prior to receipt of explosive materials by the purchaser.

10. The seller will complete Section B and retain one copy of the form
as record of disposition for the required record retention period in
accordance with 27 CFR 555.121.
11. The seller will submit the original copy of ATF Form 5400.4 to ATF
Firearms and Explosives Licensing Center, 244 Needy Road,
Martinsburg, WV 25405.

Privacy Act Information

The following information is provided pursuant to Section 3 of the
Privacy Act of 1974 [5 U.S.C. Section 552a(3)]:

1. Authority. Solicitation of this information is made pursuant to
18 U.S.C. Sections 842 and 843. Disclosure of this information is
mandatory.
2. Purpose. To identify the permittee, distributor, and the explosive
materials.
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 Federal, State, foreign and local law enforcement and regulatory agency personnel to verify information on the
form and to aid in the performance of 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 the
publicin order to verify the information on the form where such disclosure is not prohibited by law.
Paperwork Reduction Act Notice

12. Where possession of explosive materials is transferred directly to
the distributee at the seller’s premises, the seller must obtain an
executed ATF form 5400.4 and verify the identity of the person
accepting possession of the explosive materials. In instances
where an employee truck driver of the distributor delivers the
explosive materials to the premises of the purchaser, the
distributor’s employee truck driver will check item 2A, Section B.

This request is in accordance with the Paperwork Reduction Act of 1995.
The purpose of this information collection is to verify that all persons
who are purchasing explosive materials have the proper Federal permit
and to ensure that such person have appropriate facilities for storage of
the explosive materials. The information is subject to inspection by ATF
officials. This information request is 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 or contract carrier will transport explosive
materials from the distributor to a holder of a limited permit, the
limited permittee will, prior to delivery of the explosive materials
complete Section A on ATF Form 5400.4, affix to the form one of
the six IPECs previously 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
contract carrier who will transport explosive materials to the
limited permittee, the distributor must obtain an executed ATF Form

The estimated average burden associated with this collection is 20 minutes per respondent or recordkeeper, depending on individual circumstances. Comments concerning the accuracy of this burden estimate
and suggestions for reducing this burden should be addressed to Reports
Management Officer, Document Services Branch, Bureau of Alcohol,
Tobacco, Firearms and Explosives, Washington, DC 20226.
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.
ATF Form 5400.4
Revised May 2003

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