Form Dpssp 4646 - Concealed Handgun Permit Suspension / Revocation Affidavit
Download a blank fillable Form Dpssp 4646 - Concealed Handgun Permit Suspension / Revocation Affidavit in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Dpssp 4646 - Concealed Handgun Permit Suspension / Revocation Affidavit with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2LOUISIANA DEPARTMENT OF PUBLIC SAFETY AND CORRECTIONS
OFFICE OF STATE POLICE
Concealed Handgun Permit Suspension / Revocation Affidavit
STATE OF LOUISIANA
_____________________________
Parish of
BEFORE ME, the undersigned authority, duly qualified, personally came and appeared,__________
______________________________
, who by me first being duly sworn, deposed as follows:
_____________________________________
I,
, a duly commissioned, law enforcement officer,
___________,
___________________________________
identification number,
employed by
,
______________________________
____
__________________
address,
, phone number (
)
,
who has reasonable grounds to believe, and does believe, that the concealed handgun permit holder
______________________________
_____________________
herein named,
, OLN/I.D. No.,
,
____
______________
________
State,
, Concealed Handgun Permit No.,
, whose date of birth is,
,
______________________________________________________________
and resides at
,
(address)
(city)
(state)
1.
Refused to submit to a department certified chemical test at the direction of a law
___
____________
___
enforcement officer on the
day of
, 20
. (A copy of the report
relating to this incident is attached hereto.)
2.
Submitted to a department certified chemical test that indicated a blood alcohol concentration
___
of .05 grams percent of higher by weight of alcohol in the blood. Results of .
g%. (A
copy of the test results along with a copy of the report relating to this incident are attached
hereto.)
3.
Submitted to a department certified blood test which indicated the presence of:
___
A.
an alcohol concentration of .05 grams percent or higher by weight of alcohol in
___
the blood. Results of .
g%.
___
B.
a controlled dangerous substance (CDS) as defined in R.S. 40:961 and 40:964.
__________________________________________________
Name of CDS
.
(A copy of the report relating to this incident is attached hereto.)
4.
Submitted to a department certified urine test which indicated the presence of:
___
A.
an alcohol concentration of .05 grams percent or higher by weight of alcohol in
___
the blood. Results of .
g%.
___
B.
a controlled dangerous substance (CDS) as defined in R.S. 40:961 and 40:964.
__________________________________________________
Name of CDS
.
(A copy of the report relating to this incident is attached hereto.)
DPSSP 4646 (Rev. 06/14)
Page 1 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal