BPA F 5632_12e Evidence/Property Custody Document

BPA F 5632.12e
(09-19)

U.S. DEPARTMENT OF ENERGY-BONNEVILLE POWER ADMINISTRATION(BPA)

EVIDENCE/PROPERTY CUSTODY DOCUMENT

OMB Control Number:1910-5188
Expiration Date: 08/31/2022

Page 1 of 3

INSTRUCTIONS: Originator to complete sections 1-8. Forward completed form and evidence to the Security Office NNT-1. Security
Office will safe keep all evidence/property until final determination is reached, except when cyber related.
1. BPA Case Number:

2. Law Enforcement Case Number:

3. Receiving Organization:

4. Type (Check one):
Evidence
Found Property

5. Name, Grade And Title of Person From Whom Received:
Owner

6. Location Evidence/Property Obtained:

Other

7. Name of Person Receiving Evidence:

8. Date/Time Obtained:

9. DESCRIPTION OF ARTICLES (List one item per line)
Item
Number

Description
(Include model, serial number, condition and unusual marks or scratches)

Quantity

10. CHAIN OF CUSTODY
Item
Number

Date/Time

Released By

Received By

Signature:

Signature:

Name, Grade or Title:

Name, Grade or Title:

Signature:

Signature:

Name, Grade or Title:

Name, Grade or Title:

Signature:

Signature:

Name, Grade or Title:

Name, Grade or Title:

Signature:

Signature:

Name, Grade or Title:

Name, Grade or Title:

Purpose of Change
of Custody

FILE CODE: SS-18-15 RETENTION: NNT = 2 YRS

BPA F 5632.12e

U.S. DEPARTMENT OF ENERGY-BONNEVILLE POWER ADMINISTRATION (BPA)

(09-19)

EVIDENCE/PROPERTY CUSTODY DOCUMENT

OMB Control Number: 1910-5188
Expiration Date: 08/31/2022

Page 2 of 3

10. CHAIN OF CUSTODY (Continued)
Item
Number

Date/Time

Released By

Received By

Signature:

Signature:

Name, Grade or Title:

Name, Grade or Title:

Signature:

Signature:

Name, Grade or Title:

Name, Grade or Title:

Signature:

Signature:

Name, Grade or Title:

Name, Grade or Title:

Signature:

Signature:

Name, Grade or Title:

Name, Grade or Title:

Signature:

Signature:

Name, Grade or Title:

Name, Grade or Title:

Signature:

Signature:

Name, Grade or Title:

Name, Grade or Title:

Signature:

Signature:

Name, Grade or Title:

Name, Grade or Title:

Signature:

Signature:

Name, Grade or Title:

Name, Grade or Title:

Purpose of Change
of Custody

11. FINAL DISPOSITION
Release to Owner
(Name/Organization):
Destroy:
Other (Specify):

FILE CODE: SS-18-15 RETENTION: NNT = 2 YRS

BPA F 5632.12e
(09-19)

U.S. DEPARTMENT OF ENERGY-BONNEVILLE POWER ADMINISTRATION (BPA)

EVIDENCE/PROPERTY CUSTODY DOCUMENT

OMB Control Number:1910-5188
Expiration Date: 08/31/2022

Page 3 of 3

12. FINAL DISPOSITION AUTHORITY
Item Number(s)

on this document, pertaining to the inquiry/investigation involving
(is)(are) no longer

(Name)

(Grade)

(Organization)

required as evidence and may be disposed of as indicated above (if articles must be retained do not sign, explain in separate page).

Name, Grade, Title, Organization
Item number(s)

Signature
13. WITNESS TO DESTRUCTION OF EVIDENCE

Date

(was) (were) destroyed by the Evidence Custodian in my presence, on the date indicated

above.

Name, Grade, Title, Organization

Signature

Date

Paperwork Reduction Act Burden Disclosure Statement
This data is being collected to ensure the security and safety of BPA employees, contractors, and facilities,. The data you supply will be used by
BPA Security to document chain of custody of evidence or property. Public reporting burden for this collection of information is estimated
to average .10 hours per response, including the time for reviewing instructions, searching exiting data sources, gathering and
maintaining that data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing this burden, to Office of the Chief Information
Officer, Enterprise Policy Development & Implementation Office, IM-22, Paperwork Reduction Project (OMB control number 1910-5188),
U.S. Department of Energy, 1000 Independence Ave SW, Washington, DC, 20585-1290; and to the Office of Management and Budget (OMB),
OIRA, Paperwork Reduction Project (OMB control number 1910-5188), Washington, DC 20503.
Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty for failure to
comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays
a currently valid OMB control number.
The Paperwork Reduction Act (PRA) of 1995 requires each Federal agency to seek and obtain approval from the Office of Management and Budget
(OMB) before undertaking a collection of information directed to 10 or more persons of the general public, including persons involved in or supporting
the operations of Government-owned, contractor-operated facilities.
Submission of this data is required.

FILE CODE: SS-18-15 RETENTION: NNT = 2 YRS