U.S. Department of Justice
Bureau of Alcohol, Tobacco, Firearms and Explosives
OMB No. 1140-0020
Firearms Transaction Record Part I -
Over-the-Counter
WARNING: You may not receive a firearm if prohibited by Federal or State law. The information you provide will
be used to determine whether you are prohibited under law from receiving a fi,·earm. Certain violations of the Gun
Control Act, 18 U.S.c. §§ 92] et. seq., are punishable by up to 10 years imprisonment andlor up to a $250,000 fine.
Prepare in original only. All entries must be handwritten in ink. Read the Notices, Instructions, and Definitions on
this form. "PLEASE PRINT."
Section A - Must Be Completed Personally By Transferee (Buyer)
Transferor's Transaction
Serial Number
(If
any)
I. Transferee's Full Name
Last Name
I
First Name
I
MiddJe Name (Ifno middle name, state "il/AIN")
J
2.
Current Residence Address (U.S. Postal abbreviations are acceptable. Cannot be a post office box.)
Number and Street Address
City
Couniy
State
IZIP
Code
I
3.
Place of Birth
4. Height
5. Weight
6. Gender
7. Birth Date
U.S. Ciiy and State
-OR-
I
Foreign Country
Ft. _ _
(Lbs.)
Malc
0
Month
I
Day
I
Year
I
In.
- - -
Female
0
I
8.
Social Security Number (Optiollal. but
will
help prevent misidentification)
9. Unique Personal Identification Number (UPIN) if applicable (See
Insh1./ctionsfor Question 9.)
10.
Race (Ethnicity) (Check one or more boxes. See Instnlctions jor Question 10.)
o
American Indian or Alaska Native
0
Black or African American
o
Hispanic or Latino
0
Asian
o
Native Hawaiian or Other Pacific Islander
o
White
II.
!\nswer questions Il.a. (see exceptions) through II.!. and
12 (If applicable) by
checking or marking
'Yes"
or "no" in the boxes to the right ofthe questions.
a.
Are you the actual transfereelbuyer of the firearm(s) listed on this form? Warning: You are not the actual buyer if you are
Yes
No
acquiring the firearm(s) on behalf of another person. If you are not the actual buyer, the dealer cannot transfer the firearm(s
D
D
to you. (See InstrifctiollS for Question II.a.) Exception: If)'ou are picking lip a repaired firearmM for another person, you are not
reqifired to answer II.a. and may proceed to question II.b.
b.
Are you under indictment or information in any court for a felony, or any other crime, for which the judge could imprison you for
Yes
No
more than one vear? (See Imtructions for Question II.b.)
D
D
c.
Have you ever been convicted in any coun of a felon}', or any other crime, for which the judge could have imprisoned you for more
Yes
No
than one Year, even if YOU received a shorter sentence including probation? (See Instructions for Question II.c.)
D
D
d.
Are you a fugitive from justice?
Pl
No
n
e.
Are you an unlawful user of, or addicted to, marijuana or any depressant, stimulant, narcotic drug, or any other controlled substance?
IJ
No
n
f.
Have you ever been adjudicated mentally defective (which includes a determination by a court. board. commission, or other lawful
authority that you are a danger
to
yourse({or to others or are incompetent to manage YOllr own affair;) OR have you ever been
Yes
No
committed to a mental institution? (See Instructions/or Question II.()
D
D
g.
Have you been discharged from the Armed Forces under dishonorable conditions'?
Pl
No
D
h.
Are you subject to a court order restraining you from harassing, stalking, or threatening your child or an intimate partner or child of
Yes
No
such partner'? (See Instructions for Question IIh.)
D
D
i.
Have you ever been convicted in any court of a misdemeanor crime of domestic violence? (See Instructions/or Question II.i.)
Pl
No
f!
j.
Have you ever renounced your United States citizenship?
Yes
No
[J
n
k.
Arc you an alien illegally in the United States')
Yes
1'io
D
D
L
Are you a nonimmigrant alien? (See Instructions.f(Jr Question 11.1.) Ifyou answered "no" to this question, do NOT re;pond to
Yes
No
question 12 and proceed to question 13.
D
0
12.
Jf you are a nonimmigrant alien, do you fall within any of the exceptions set forth in the instructions? (If "yes," the licensee must
Yes
No
complete question 20d.) (See Inslntetions for Question 12.) If question I II. is answered with a "no" response, then do NOT
0
0
resoond to auestion 12 and oroceed to auestion 13.
13.
\Vhat is your State of residence 14. What is your country of citizenship? (List/check more than
1
S. lfyou are not a citizen of the United States,
(if any)? (See Instructionsfor
one, ifapplicable. Ifyou are a citizen ofthe United States,
what is your U.S.-issued alien number or
Question 13.)
proceed to question 16.)
o
United States of America
admission number?
o
Other
(:;y
'r
Notc: PrcvlOus Editions Arc Obsolete
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ATF Form 4473 (5300.9) Part J
Revised August 2008