Free 52776.FH11 - Indiana

Reset Form

VALUABLE METAL DEALER REPORT RESOLD METAL PRODUCTS
State Form 52776 (R3 / 7-09) / 5PS415 INDIANA STATE POLICE

* This state agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1. Disclosure is voluntary and you will not be penalized for refusal.

Pursuant to IC 25-37.5-1 Valuable metal dealer required to keep form, copy of government identification, and photograph of seller and valuable metal for two (2) years.
Name of buyer / firm Address (number and street, city, state, and ZIP code) Place of purchase Name of seller (list additional persons on back of form) Address (number and street, city, state, and ZIP code) Name of Government agency issuing photographic identification Drivers license number or Social Security number * Year of vehicle used to deliver metal Description of metal Weight of metal (pounds) Signature of seller Make of vehicle Government-issued photographic identification number License plate number Model of vehicle Source of valuable metal Price paid Date (month, day, year) Color of vehicle Date of birth (month, day, year) Date of purchase (month, day, year) County

Reset Form

VALUABLE METAL DEALER REPORT RESOLD METAL PRODUCTS
State Form 52776 (R3 / 7-09) / 5PS415 INDIANA STATE POLICE

* This state agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1. Disclosure is voluntary and you will not be penalized for refusal.

Pursuant to IC 25-37.5-1 Valuable metal dealer required to keep form, copy of government identification, and photograph of seller and valuable metal for two (2) years.
Name of buyer / firm Address (number and street, city, state, and ZIP code) Place of purchase Name of seller (list additional persons on back of form) Address (number and street, city, state, and ZIP code) Name of Government agency issuing photographic identification Drivers license number or Social Security number * Year of vehicle used to deliver metal Description of metal Weight of metal (pounds) Signature of seller Make of vehicle Government-issued photographic identification number License plate number Model of vehicle Source of valuable metal Price paid Date (month, day, year) Color of vehicle Date of birth (month, day, year) Date of purchase (month, day, year) County