<table style="width:100%;">
<colgroup>
<col style="width: 8%" />
<col style="width: 5%" />
<col style="width: 10%" />
<col style="width: 13%" />
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 5%" />
<col style="width: 10%" />
<col style="width: 9%" />
<col style="width: 0%" />
<col style="width: 14%" />
</colgroup>
<tbody>
<tr class="odd">
<td><h2 id="section"><img src="media/image1.wmf" /></h2></td>
<td colspan="4"><h2 id="statement-of-special-moneys-and">Statement of
Special Moneys and </h2>
<h2 id="property-transaction">Property Transaction</h2></td>
<td colspan="2"><ol type="1">
<li><p><strong>Division</strong></p></li>
</ol>
<p>     </p></td>
<td colspan="2"><p><strong>2. Post of Duty</strong></p>
<p>     </p></td>
<td colspan="2"><p><strong>3. Control Number</strong></p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="5"><p><strong>4. Name</strong></p>
<p>     </p></td>
<td colspan="4"><p><strong>5. Title</strong></p>
<p>     </p></td>
<td colspan="2"><p><strong>6. Date</strong></p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="3"><strong>7. Receipts</strong></td>
<td colspan="3"><p><strong>8. Disposals (Check One):</strong></p>
<p> <strong>Transfer</strong> <strong>Refund</strong>
<strong>Deposit</strong></p></td>
<td colspan="3"><p><strong>Closing Status (Check One):</strong></p>
<p> <strong>Forfeiture</strong> <strong>Returned</strong></p></td>
</tr>
<tr class="even">
<td colspan="2"><p><strong>Description</strong></p>
<p><strong>7(a)</strong></p></td>
<td><p><strong>Date</strong></p>
<p><strong>7(b)</strong></p></td>
<td><p><strong>Name &amp; Case Number</strong></p>
<p><strong>7(c)</strong></p></td>
<td><p><strong>Amount</strong></p>
<p><strong>7(d)</strong></p></td>
<td><p><strong>Date</strong></p>
<p><strong>8(a)</strong></p></td>
<td colspan="2"><p><strong>Name &amp; Case Number</strong></p>
<p><strong>8(b)</strong></p></td>
<td colspan="2"><p><strong>Amount</strong></p>
<p><strong>8(c)</strong></p></td>
<td><p><strong>To Whom</strong></p>
<p><strong>8(d)</strong></p></td>
</tr>
<tr class="odd">
<td colspan="2">Recovered moneys held as evidence</td>
<td>     </td>
<td><p>     </p>
<p>     </p></td>
<td>0.00</td>
<td>     </td>
<td colspan="2"><p>     </p>
<p>     </p></td>
<td colspan="2">0.00</td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="2"><strong>Moneys held for safekeeping</strong></td>
<td>     </td>
<td><p>     </p>
<p>     </p></td>
<td>0.00</td>
<td>     </td>
<td colspan="2"><p>     </p>
<p>     </p></td>
<td colspan="2">0.00</td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="2"><h4 id="bribe-moneys">Bribe Moneys</h4></td>
<td>     </td>
<td><p>     </p>
<p>     </p></td>
<td>0.00</td>
<td>     </td>
<td colspan="2"><p>     </p>
<p>     </p></td>
<td colspan="2">0.00</td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="2"><h4 id="seized-property">Seized Property:</h4>
<p>     </p>
<p>     </p>
<p>     </p>
<p>     </p>
<p>     </p>
<p>     </p></td>
<td><p>     </p></td>
<td><p>     </p>
<p>     </p></td>
<td><p>0.00</p>
<p>0.00</p>
<p>0.00</p>
<p>0.00</p>
<p>0.00</p>
<p>0.00</p></td>
<td><p>     </p></td>
<td colspan="2"><p>     </p>
<p>     </p></td>
<td colspan="2"><p>0.00</p>
<p>0.00</p>
<p>0.00</p>
<p>0.00</p>
<p>0.00</p>
<p>0.00</p></td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="2"><h3 id="total">TOTAL</h3></td>
<td></td>
<td></td>
<td>     </td>
<td></td>
<td colspan="2"></td>
<td colspan="2">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="4"><strong>9. Location</strong></td>
<td colspan="2"><h5 id="amount">Amount</h5></td>
<td colspan="5"><p><strong>10. I certify that the above is a full, true,
and a correct statement of all</strong></p>
<p><strong>moneys received or disposed of on this
date.</strong></p></td>
</tr>
<tr class="odd">
<td colspan="4"><h4 id="cash-in-office-safe">Cash in Office
Safe</h4></td>
<td colspan="2">$      </td>
<td colspan="5"><strong>Signature:</strong></td>
</tr>
<tr class="even">
<td colspan="4"><h4 id="in-safety-deposit-box">In Safety Deposit
Box</h4></td>
<td colspan="2">$      </td>
<td colspan="5"><strong>Title:</strong>      </td>
</tr>
<tr class="odd">
<td colspan="4"><h4 id="bureau-of-public-debt">Bureau of Public
Debt</h4></td>
<td colspan="2">$      </td>
<td colspan="5"><p id="date" class="heading">Date:      </p></td>
</tr>
<tr class="even">
<td colspan="4"><strong>Other (describe):</strong>      </td>
<td colspan="2">$      </td>
<td colspan="5"></td>
</tr>
</tbody>
</table>

**INSTRUCTIONS FOR PREPARING FORM OI 141**

1.  Prepare a separate Form OI 141 for each case. If there is more than
    one seizure on the same date for a single case, note each seizure
    amount separately on the same Form OI 141. If there is more than one
    seizure on different dates for a single case, note each seizure on a
    separate Form OI 141.

2.  Enter the division, post of duty, name, and title of the responsible
    agent in items 1, 2, 4, and 5, respectively.

3.  Enter the date the Form OI 141 is prepared in item 6.

4.  In reporting receipts, record the seizure date in item 7(b), the
    name and case number in item 7(c), and the amount of the monies or
    fair market value for each property item listed in item 7(a) or in
    an attachment, in item 7(d).

5.  Enter the location of the monies or property in item 9.

6.  In reporting disposals for all monies and property, check the
    appropriate box for **FORFEITED** or **RETURNED** in item 8, enter
    the date of the final disposition in item 8(a), the name and case
    number in item 8(b), and the amount of monies or fair market value
    for each property item listed in 7(a) or in an attachment, in item
    8(c). For moneys or seized property **RETURNED** to the defendant,
    relative, non-profit organization, etc., obtain a signed receipt
    witnessed by at least two agents and forward the original receipt
    and one copy with the Form OI 141 to the Divisional Seized Assets
    PPM Program Coordinator. For monies **FORFEITED** to the federal
    government, forward a money order or cashier's check made payable to
    TIGTA, attach the completed Form OI 141 and record in item 8(d) that
    the money order or cashier's check is to be sent to BPD for deposit
    into the Federal Reserve Bank. In all instances, the amounts
    reported in 8(c) must be the same as the amounts initially reported
    in item 7(d) under receipts. Appreciation or depreciation of
    property is not to be considered.

7.  Special Agent is to enter his/her signature, title and date signed
    in item 10. Electronic signatures are acceptable.

8.  Special Agents are to prepare an original and three copies and
    distribute as follows:

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(a) Special Agent retains one copy for his/her file and sends the
    original and two copies to the Divisional Seized Assets PPM Program
    Coordinator.

(b) Divisional Seized Assets PPM Program Coordinator forwards the
    original and one copy and any other pertinent documentation to the
    Nationwide Seized Assets PPM Program Coordinator and retains a copy
    of the Form OI 141 and all documentation in the divisional files.

(c) The Nationwide Seized Assets PPM Program Coordinator inserts a
    control number in item 3 on the original Form OI 141 and enters the
    required information in the PPM database. **Each case** is assigned
    one control number. On any subsequent Forms OI 141 relating to the
    same case, the Divisional Seized Assets PPM Program Coordinator
    should enter the assigned control number in item 3.

**DEFINITIONS**

**Forfeited**: Ownership of the seized monies or seized property is
transferred from the original owner to another entity. For example,
seized monies given to the IRS for taxes owed or given to the Federal
Reserve Bank for deposit into miscellaneous receipts or seized property
is destroyed, given to a non-profit organization or maintained by TIGTA
in its undercover equipment inventory, etc.

**Returned**: Ownership of the seized monies or seized property is
returned to the original owner. For example, the seized monies or seized
property is returned to the defendant, to the spouse, a relative, etc.