Form Chl-81 - Affidavit For Suspension - Texas Department Of Public Safety printable pdf download

SUSPENSION FORM

OFFICER’S AFFIDAVIT FOR SUSPENSION OF CONCEALED HANDGUN LICENSE AND/OR INSTRUCTOR’S CERTIFICATE

UNDER GOVERNMENT CODE SECTION 411.187

STATE OF __________________________________________ §

(STATE WHERE NOTARIZED)

COUNTY OF ________________________________________ §

(COUNTY WHERE NOTARIZED)

BEFORE ME, the undersigned authority, personally appeared ________________________________, known to

(PRINTED NAME AFFIANT)

me to be a credible person, who being duly sworn, deposed as follows:

My name is _______________________________________________________________, and I am a Texas

Peace Officer employed by _________________________________________, ORI No.____________________________,

Identification No. ______________________.

The license holder’s name is ____________________________________________________________________,

Concealed Handgun License No. _______________________, and/or Instructor Certificate No. ______________________;



TX DL /

Identification No. ____________________________, whose date of birth is

___________________,

(MM/DD/YYYY)

who resides at ______________________________________________, and whose phone No. is ( ___ ) _____________.

(STREET, CITY, STATE, ZIP)

(AREA CODE & NUMBER)

I believe that the following grounds exist to suspend the license to carry a concealed handgun or certificate as a concealed

handgun instructor:

(PUT A CHECK MARK IN THE BOX(ES) THAT APPLY)



1. The license holder has been formally charged with the commission of : a felony under an information or indictment

 

Class A or Class B misdemeanor

 

Class C offense under Section 42.01 Penal Code

Cause No.______________________ in the ___________________________ Court of ______________________________,

on ____________________________________. Date of offense/incident __________________________________________

and specific charge(s)___________________________________________________________________________________.

Did offense/incident involve family violence? YES NO If yes, relationship of suspect to victim ____________________.

Was the suspect’s concealed handgun involved in offense/incident? YES NO 

2. The license holder failed to notify the Department of a change in address or name as required, when the address or name

changed.

3. The license holder carried a semi-automatic category of concealed handgun when the license holder was licensed to carry only

a non-semi-automatic category of concealed handgun.

4. The license holder failed to return a previously issued license after the license was modified to carry a ____________________

category of concealed handgun on __________________________________.

a). Was the license surrendered to officer? YES NO 

Note: If license was surrendered to officer, please return license to: Regulatory Services Division MSC 0245, Texas Department of

Public Safety, PO Box 4087, Austin, TX 78773-0245.

b). The Following exhibits are attached to the affidavit and incorporated by reference:

________________________________________________________________________________________________

___________________________________________

PEACE OFFICER/AFFIANT Signature

AGENCY ADDRESS:

AGENCY PHONE No.:

SUBSCRIBED and SWORN TO before me, this _______ day ____________________________, 20______.

(DAY)

(MONTH)

(YEAR)

_________________________________________

NOTARY PUBLIC Signature

[seal]

_________________________________________

Printed Name of NOTARY PUBLIC (if not on seal)

PEACE OFFICER:

SEND AFFIDAVIT ALONG WITH ATTACHMENTS WITHIN 5 DAYS AFTER THE AFFIDAVIT

IS PREPARED TO: REGULATORY SERVICES DIVISION MSC 0245, TEXAS DEPARTMENT OF

PUBLIC SAFETY, PO BOX 4087, AUSTIN TX 78773-0245

SEND COPY OF AFFIDAVIT AND ATTACHMENTS TO LICENSE HOLDER

CHL-81 (Rev. 02/11)

Form Chl-81 - Affidavit For Suspension - Texas Department Of Public Safety

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