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TRANSFEREE INFORMATION

The following questions must be answered by any transferee who is not a Federal firearms licensee or government agency. The transferee shall give full details on a separate sheet

for all “YES” answers. (See instruction 2d)

13. ARE YOU:

YES

NO 14. HAVE YOU:

YES

a. Charged by information or under indictment in any court for

a. Been convicted in any court of a crime for which the

a crime punishable by imprisonment for a term exceeding

judge could have imprisoned you for more than one

one year?

year, even if the judge actually gave you a shorter

sentence?

b. A fugitive from justice?

b. Been discharged from the armed forces under dishonorable

c. An alien who is illegally or unlawfully in the United States?

conditions?

d. Under 21 years of age?

c. Been adjudicated mentally defective or been committed

e. An unlawful user of or addicted to, marijuana, or any depres-

to a mental institution?

sant, stimulant, or narcotic drug, or any other controlled sub-

d. Renounced your United States citizenship?

stance?

e. Been convicted in any court of a misdemeanor crime of domestic

f. Subject to a court order restraining you from harassing,

violence? This includes any misdemeanor conviction involving the

stalking or threatening an intimate partner or child of such

use or attempted use of physical force committed by a current or

partner?

former spouse, parent, or guardian of the victim, or by a person with

a similar relationship with the victim.

16. PHOTOGRAPH

15. TRANSFEREE’S CERTIFICATION (See instruction 2e)

, have a reasonable necessity to

(Name of Transferee)

possess the machinegun, short-barreled rifle, short-barreled shotgun, or destructive device described on this

application for the following reason(s)

AFFIX

RECENT PHOTOGRAPH HERE

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

(Approximately 2" x 2")

178.98).

(See instruction 2f.)

UNDER PENALTIES OF PERJURY, I declare that I have examined this application and the documents submitted in

support thereof, and to the best of my knowledge and belief it is true, correct and complete.

(Signature of Transferee)

(Date)

17. LAW ENFORCEMENT CERTIFICATION (See instruction 2e)

I certify that I am the chief law enforcement officer of the organization named below having jurisdiction in the area of residence of

. I have no information indicating that the transferee will use the firearm or device

(Name of Transferee)

described on this application for other than lawful purposes. I have no information that the receipt or possession of the firearm or device described in item 4

would be place the transferee in violation of State or local law.

(Signature and Title of Chief Law Enforcement Officer)

(Date)

(Organization and Street Address)

(County)

(Telephone Number)

IMPORTANT INFORMATION FOR CURRENTLY REGISTERED FIREARMS

If this registration document evidences the current registration of the firearm described on it, please note the following information.

ESTATE PROCEDURES: For procedures regarding the transfer of firearms in an estate resulting from the death of the registrant identified in item 2a, the executor should contact the NFA

Branch, Bureau of Alcohol, Tobacco and Firearms, Washington, DC 20226.

CHANGE OF ADDRESS: Unless currently licensed under the Gun Control Act, the registrant shall notify the NFA Branch, Bureau of Alcohol, Tobacco and Firearms, Washington, DC

20226, in writing, of any change to the address in Item 2a.

CHANGE OF DESCRIPTION: The registrant shall notify the NFA Branch, Bureau of Alcohol, Tobacco and Firearms, Washington, DC 20226, in writing, of any change to the description of

the firearm in Item 4.

INTERSTATE MOVEMENT: If the firearm identified in item 4 is a machinegun, short-barreled rifle, short-barreled shotgun, or destructive device, the registrant may be required by 18

U.S.C. § 922(a)(4) to obtain permission from ATF prior to any transportation in interstate or foreign commerce.

RESTRICTIONS ON POSSESSION: Any restriction (see approval block on face of form) on the possession of the firearm identified in item 4 continues with the further transfer of the

firearm.

PERSONS PROHIBITED FROM POSSESSING FIREARMS: If the registrant becomes prohibited by 18 U.S.C. § 922 from possessing a firearm, the registrant shall notify the NFA Branch,

Bureau of Alcohol, Tobacco and Firearms, Washington, DC 20226, in writing, immediately upon becoming prohi-bited for guidance on the disposal of the firearm.

PROOF OF REGISTRATION: This approved application is the registrant’s proof of registration and it shall be made available to any ATF officer upon request.

ATF F 4 (5320.4) (8-2001)

Form Atf F 4 (5320.4) - Application For Tax Paid Transfer And Registration Of Firearm - Department Of Treasury Page 2

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