Name of Supplier: Name of Company or Person Form was submitted to.
Date Form Submitted: Date entered on DEA 222 Form.
Name of Item: List all products ordered on each DEA 222 Form. Use a separate line for each product.
Amount Ordered: Enter amount listed in No. of Packages block on DEA 222 Form.
Amount Received: Enter Amount and Date Received. If product is received in two shipments, a separate line is required for each shipment.
Note: This record does not relieve you of the responsibility of retaining copies of each separate DEA Form 222 in your records. Copies of each DEA Form 222 must be annotated to reflect the amount of merchandise received and the date received. The purpose of this record is to maintain accountability of all DEA Form 222’s.