Fillable Nys Firearms License Request For Public Records Exemption printable pdf download

Nys Firearms License Request For Public Records Exemption

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NYS Firearms License Request for Public Records Exemption

Pursuant to section 400.00 (5) (b) of the NYS Penal Law

I am: [ ] an applicant for a firearms license [ ] currently licensed to possess a firearm in NYS

Name ____________________________________________ Date of Birth_____________________

Address_________________________________________ City_________________ State________

Firearms License # (if applicable) ____________________________ Date Issued________________

Licensing Authority / County of Issuance or Application _____________________________________

I hereby request that any information concerning my firearms license application or firearms

license not be a public record. The grounds for which I believe my information should NOT be

publicly disclosed are as follows: (check all that are applicable)

[ ] 1. My life or safety may be endangered by disclosure because:

[ ]

I am an active or retired police officer, peace officer, probation officer, parole officer, or

corrections officer;

[ ]

I am a protected person under a currently valid order of protection;

[ ]

I am or was a witness in a criminal proceeding involving a criminal charge;

[ ]

I am participating or previously participated as a juror in a criminal proceeding, or am or was a

member of a grand jury;

[ ] 2. My life or safety or that of my spouse, domestic partner or household member may be endangered by

disclosure for some other reason explained below: (Must be explained in item 5 below)

[ ] 3. I am a spouse, domestic partner or household member of a person identified in A, B, C or D of question 1.

(Please check any that apply)

A _____ B_____ C_____ D_____

[ ] 4. I have reason to believe that I may be subject to unwarranted harassment upon disclosure.

5. (Please provide any additional supportive information as necessary)

__________________________________________________________________________________________

I understand that false statements made herein are punishable as a class A misdemeanor. I further

understand that upon discovery that I knowingly provided any false information, I may be subject

to criminal penalties and that this request for an exemption shall become null and void.

_____________________________________________________

________________________

Signature

Date

Nys Firearms License Request For Public Records Exemption

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