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OMB No. 1140-0011 (06/30/2016)

U.S. Department of Justice

Bureau of Alcohol, Tobacco, Firearms and Explosives

Application to Make and Register a Firearm

ATF Control Number

To: National Firearms Act Branch, Bureau of Alcohol, Tobacco, Firearms and Explosives, P.O. Box 530298, Atlanta, GA 30353-0298

(Submit in duplicate. See Instructions attached.)

Type of Application (check one)

As required by Sections 5821(b), 5822, and 5841 of the National Firearms Act, Title 26 U.S.C., Chapter 53, the undersigned

hereby submits application to make and register the firearm described below.

a. Tax Paid. Submit your tax payment of $200

Application is made by:

3a. Trade Name (If any)

with the application. The tax may be paid

Individual

Corporation or Other

Government

by credit or debit card, check, or money order.

Legal Entity

Entity

Please complete item 17. Upon approval of

3b. Applicant’s Name and Mailing Address (Type or print below and between the dots) (See instruction 2d)

the application, we will affix and cancel the

required National Firearms Act Stamp.

(See instructions 2c and 3)

b. Tax Exempt because firearm is being made on

behalf of the United States, or any department,

independent establishment, or agency thereof.

c. Tax Exempt because firearm is being made by

3c. If P.O. Box is Shown Above, Street Address Must Be Given Here

or on behalf of any State or possession of the

United States, or any political subdivison

thereof, or any official police organization of

3e. Telephone Area Code and Number

3d. County

such a government entity engaged in criminal

investigations.

Description of Firearm (complete items a through i) (See instruction 2j)

Name and Location of Original Manufacturer of Firearm

Type of Firearm to be made

Caliber or

Model

(Receiver) (If prototype, furnish plans and specifications)

(See instruction 1c)

Gauge

(Specify

Length

e. Of Barrel:

f. Overall:

one)

(Inches)

Serial Number

Additional Description (Include all numbers and other identifying data to

State Why You Intend To Make Firearm (Use additional sheet if necessary)

include maker’s name, city and state which will appear on the firearm)

(use additional sheet if necessary)

No (See Definition 1k)

j. Is this firearm being reactivated?

Yes

Special (Occupational) Tax Status (If applicable) (See definition 1f)

Applicant’s Federal Firearms License (If any)

(Give complete 15-digit Number)

Employer Identification Number

Class

Important: All individual applicants (including Federally Licensed Collectors) must complete the reverse side of this form and submit, in duplicate, FBI Form FD-258,

Fingerprint Card.

Under Penalties of Perjury, I Declare that I have examined this application, including accompanying documents, and to the best of my knowledge and belief it is

true, accurate and complete and the making and possession of the firearm described above would not constitute a violation of Chapter 44, Title 18, U.S.C., Chapter 53,

Title 26, U.S.C., or any provisions of State or local law.

Signature of Applicant

Name and Title of Authorized Official

Date

The space below is for the use of the Bureau of Alcohol, Tobacco, Firearms and Explosives

By authority of the Director, Bureau of Alcohol, Tobacco, Firearms and Explosives, this application has been examined and the applicant’s making and registration of

the firearm described above is:

Approved (With the following conditions, if any)

Disapproved (For the following reasons)

Authorized ATF Official

Date

ATF Form 1 (5320.1)

Revised June 2014