d Name/Agency: Printed Manic/Agency: Reas Reason: Relinquished Custody Date and Time Accepted Custody Date and Time Signature: Signature: Prirted Name/Agency: Primed Name/Agency: Reason: Reason: Firearm Certification by (FI/SWAT) / Explosive Material Certification by (SABT): Printed Name: Signature:

y: Printed Name/Agency: --........„,, ) Reason: Reason: i Accepted Custody Date and Time Relinquished Custody Time Signature: Signature: Prirted Name/Agency: Printed Name/Agency: Reason: Reason: Firearm Certification by (Fl/SWAT) / Explosive Material Certification by (SABT): Printed Name: Signature: