EFTA00132028



FD-1004
Rev. 7-7-2016


FEDERAL BUREAU OF INVESTIGATION
EVIDENCE CHAIN OF CUSTODY

Evidence Type: □ General □ Drugs □ Firearms/Weapon
□ Digital □ Valuables □ Firearms/Other

Special Handling Instructions

☐ HAZMAT ☐ Latents ☐ FGJ
☐ Req. Charging ☐ Freeze ☐ Refrigerate
☐ Biohazard
☐ Other ___

Initial Receipt

Signature of Sender:
Printed Name/Agency:
Reason:
Collected By:
Agency: FB

Date and Time

Date and Time

Date and Time

Date and Time

Date and Time

Date and Time

Date and Time

Date and Time

Firearm Certification by (FI/SWAT) / Explosive Material Certification by (SABT):

Printed Name:

Signature:

Date:

Case ID: 90A-NY-3151227

Barcode: 66516209

This form is incomplete without reference to the FD-1087.

EFTA00132029

EVIDENCE CHAIN OF CUSTODY

<table><thead><tr><th>Relinquished Custody</th><th>Date and Time</th><th>Accepted Custody</th><th>Date and Time</th></tr></thead><tbody><tr><td>Signature:</td><td rowspan="3">5/12/20<br>11:00am</td><td>Signature:</td><td rowspan="3"></td></tr><tr><td>Printed Name</td><td>Printed Name</td></tr><tr><td>Reason:</td><td>Reason:</td></tr><tr><td>Relinquished Custody</td><td>Date and Time</td><td>Accepted Custody</td><td>Date and Time</td></tr><tr><td>Signature:</td><td rowspan="3">5/12/20<br>11:00am</td><td>Signature:</td><td rowspan="3"></td></tr><tr><td>Printed Name</td><td>Printed Name/Agency:</td></tr><tr><td>Reason:</td><td>Reason:</td></tr><tr><td>Relinquished Custody</td><td>Date and Time</td><td>Accepted Custody</td><td>Date and Time</td></tr><tr><td>Signature:</td><td rowspan="3"></td><td>Signature:</td><td rowspan="3"></td></tr><tr><td>Printed Name/Agency:</td><td>Printed Name/Agency:</td></tr><tr><td>Reason:</td><td>Reason:</td></tr><tr><td>Relinquished Custody</td><td>Date and Time</td><td>Accepted Custody</td><td>Date and Time</td></tr><tr><td>Signature:</td><td rowspan="3"></td><td>Signature:</td><td rowspan="3"></td></tr><tr><td>Printed Name/Agency:</td><td>Printed Name/Agency:</td></tr><tr><td>Reason:</td><td>Reason:</td></tr><tr><td>Relinquished Custody</td><td>Date and Time</td><td>Accepted Custody</td><td>Date and Time</td></tr><tr><td>Signature:</td><td rowspan="3"></td><td>Signature:</td><td rowspan="3"></td></tr><tr><td>Printed Name/Agency:</td><td>Printed Name/Agency:</td></tr><tr><td>Reason:</td><td>Reason:</td></tr><tr><td>Relinquished Custody</td><td>Date and Time</td><td>Accepted Custody</td><td>Date and Time</td></tr><tr><td>Signature:</td><td rowspan="3"></td><td>Signature:</td><td rowspan="3"></td></tr><tr><td>Printed Name/Agency:</td><td>Printed Name/Agency:</td></tr><tr><td>Reason:</td><td>Reason:</td></tr><tr><td>Relinquished Custody</td><td>Date and Time</td><td>Accepted Custody</td><td>Date and Time</td></tr><tr><td>Signature:</td><td rowspan="3"></td><td>Signature:</td><td rowspan="3"></td></tr><tr><td>Printed Name/Agency:</td><td>Printed Name/Agency:</td></tr><tr><td>Reason:</td><td>Reason:</td></tr></tbody></table>

Case ID: 90A-M-3151227 IB: 16 Barcode: E6S16209

This form is incomplete without reference to the FD-1087.