Application For Tax Paid Transfer And Registration Of Firearm (Page 2 of 6) in pdf

Transferee Certification

12. Law Enforcement Notification (See instruction 2f)

The transferee is to provide notification of the proposed acquisition and possession of the firearm described on this Form 4 by providing a copy of the completed form to the

chief law enforcement officer in the agency identified below:

Agency or Department Name

Name and Title of Official

Address (Street address or P.O. Box, City, State and Zip Code) to which sent (mailed or delivered))

Date Sent to Agency

Information for the Chief Law Enforcement Officer

This form provides notification of the transferee’s intent to acquire and possess a National Firearms Act (NFA) firearm. No action on your part is required. However, should

you have information that may disqualify this person from acquiring or possessing a firearm, please contact the NFA Branch at (304) 616-4500 or NFA@atf.gov. A “Yes”

answer to items 14.a. through 14.j. (except 14.i.) and item 16.a could disqualify a person from acquiring or possessing a firearm. Also, ATF will not approve an application if

the transfer or possession of the firearm is in violation of State or local law.

13. Transferee Necessity Statement (See instruction 2e)

, have a reasonable necessity to possess the machinegun, short-barreled rifle,

(Name and Title of Transferee)

short-barreled shotgun, or destructive device described on this application for the following reason(s)

and my possession of the device or weapon would be consistent with public safety (18 U.S.C. § 922(b) (4) and 27 CFR § 478.98).

Transferee Questions (Complete Only When Transferee is An Individual)

14. Answer questions 14.a. through 14.h. Answer questions 16 through 17 if applicable. For any “Yes” answer the transferee shall provide details on a

separate sheet. (See instruction 7b and definitions)

15. Photograph

Yes

a. Are you under indictment or information in any court for a felony, or any other crime, for which the judge

could imprison you for more than one year? (See definition 1m)

b. Have you ever been convicted in any court for a felony, or any other crime, for which the judge could imprison you

for more than one year, even if you received a shorter sentence including probation? (See definition 1m)

Affix

c. Are you a fugitive from justice? (See definition 1s)

Recent Photograph Here

d. Are you an unlawful user of, or addicted to, marijuana or any depressant, stimulant, narcotic drug, or any

(Approximately 2” x 2”)

other controlled substance? Warning: The use or possession of marijuana remains unlawful

(See instruction 2g)

under Federal law regardless of whether it has been legalized or decriminalized for medicinal or

recreational purposes in the state where you reside.

e. Have you ever been adjudicated as a mental defective OR have you ever been committed to a mental

institution? (See definitions1n and 1o)

f. Have you been discharged from the Armed Forces under dishonorable conditions?

g. Are you subject to a court order restraining you from harassing, stalking, or threatening your child or an

intimate partner or child of such partner? (See definition 1p)

h. Have you ever been convicted in any court of a misdemeanor crime of domestic violence? (See definition 1q)

16a. Country of Citizenship: (Check/List more than one, if applicable. Nationals of the United States may check U.S.A.) (See definition 1r)

United States of America

Other Country/Countries (specify):

Yes

Have you ever renounced Unted States citizenship?

Are you an alien illegally or unlawfully in the United States?

d.1. Are you an alien who has been admitted to the United States under a nonimmigrant visa?

d.2. If “yes”, do you fall within any of the exceptions stated in the instructions? Attach the documentation to the application

N/A

17. If you are an alien, record your U.S.-Issued Alien or Admission number (AR#, USCIS#, or 194#):

CERTIFICATION: Under penalties imposed by 18 U.S.C. § 924 and 26 U.S.C. § 5861, I certify that a completed copy of this form has been sent to the chief law enforcement

officer shown in item 12, that the statements contained in this certification, and any attached documents in support thereof, are true and correct to the best of my knowledge and

belief.

Date

Signature of Transferee

ATF Form 4 (5320.4)

Revised (

)

Application For Tax Paid Transfer And Registration Of Firearm Page 2

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