KANSAS BUREAU OF INVESTIGATION

FORENSIC LABORATORY

EVIDENCE CUSTODY RECEIPT

Contributing Agency

Address/Phone

Nature of Offense

KBI Case Number

Victim:

Last	First	Middle

DOB

SOC	Sex:

Race:

Send report to:

Suspect:

Last	First	Middle

DOB

SOC	Sex:

Race:

Agency Case #

County of Offense

Agency ORI #

Use back side of this form for Additional Suspects and Victims
Exhibit

Number	Number

of Items	EXHIBIT DESCRIPTION	Requested Examination
If charges are filed under the Illegal Drug Tax Stamp Law, weighing or counting must be requested.
Previous evidence submitted in this case? Yes No	Brief Case Synopsis (see back) Yes No
Do any of the items submitted constitute a Safety or Health Hazard? (If answer is Yes, describe hazard in case synopsis) Yes No
Date collected

Printed or Typed Name of Collector

Written signature of collector
Item No's	Date	Received From (Name and Title)	Received By (Name and Title)	Purpose of Transfer
Hold
SUBMIT ORIGINAL ONLY

All Requested Information Must Be Legible

FORM KBI-L04

Rev. 7-1-98

KANSAS BUREAU OF INVESTIGATION

Curtis Geiken

2012-02-03

KBI