Firearm Affidavit Form - New York State printable pdf download

AFFIDAVIT

State of ___________________

County of __________________

Print all information clearly

___________________________________________________ being duly sworn, deposes and says:

1. That I make this affidavit in support of my application for qualification with a handgun, or handguns, at the S & K Prevention

Firearms Training Facility;

2. That I reside at:

_________________________________________________________________________________________

(Address)

(City)

(State)

(Zip Code)

______________________________________________________________________________________________________________

(Email address)

(Telephone Number)

3. That I separated from the following public agency as a law enforcement officer:

___________________________________________________________________________;

4. That my separation from the agency listed in Paragraph 3, above, was not for reasons of mental instability;

5. That at the time of my separation from the agency listed in Paragraph 3, above, I was in good standing with said agency;

6. That prior to the time of my separation from the agency listed in Paragraph 3, above, I was authorized by law to engage in or

supervise the prevention, detection, investigation, or prosecution of, or the incarceration of any person of, any violation of

law, and had statutory powers of arrest;

7. That prior to my separation from the agency listed in Paragraph 3, above, I (check one)

(A) ____ was regularly employed as a law enforcement officer for an aggregate of 10 years or more; or,

(B) ____retired from service with such agency, after completing any applicable probationary period of such

service, due to a service-connected disability, as determined by such agency;

8. That I:

a. _____ am not under the influence of alcohol or another intoxicating or hallucinatory drug and/or substance;

b. _____ have not been convicted of misdemeanor domestic violence within the meaning of 18 U.S.C. § 922(d)(9);

c. _____ am not the subject of a lawful post-hearing restraining order within the meaning of 18 U.S.C. § 922(d)(9);

d. _____ am not a convicted felon;

e. _____ am not a former U.S. citizen who renounced citizenship within the meaning of 18 U.S.C. § 922;

f. _____ am not subject to pending indictment for a crime punishable by over 1 year incarceration within the meaning of 18

U.S.C. § 922;

g. _____ am not an unlawful user or addicted to any controlled dangerous substance within the meaning of 18 U.S.C. § 922;

h. _____ am not an unlawful alien or fugitive from justice within the meaning of 18 U.S.C. § 922;

i. _____ am not otherwise prohibited any Federal, State and/or Local law from possessing a firearm;

j. _____ am not suffering from any form of dementia and/or am not presently being treated for any mental condition that

would raise a question regarding my ability to make sound judgments regarding the carry and/or use of a firearm.

That, since my separation in good standing from the agency listed in Paragraph 3, above, I have not been involved in any

action, event or condition that, if considered prior to my separation, would have prevented me from retiring in good standing;

10. That I have been trained and am currently safe and proficient in the operation of the firearm or firearms that I will use for the

purpose of qualification and that I am familiar and proficient with the safe and proper use of the holster or holsters I will use

during the qualification process. The holster or holsters that I will use during qualification is/are designed for the firearm or

firearms being fired and will be worn on my strong side.

11. That I am in compliance with all of the requirements of H.R 218, S1132 and the NY Safe act as amended.

12. That I am a permanent resident of New York State or retired from a New York State Law Enforcement agency.

________________________________________________

(Signature)

Sworn to before me this _____ day of _______________________, 20__.

________________________________________________

(Notary public)

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Firearm Affidavit Form - New York State

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