Atf E-Form 1 - Application To Make And Register A Firearm Page 8

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MAKER'S CERTIFICATION (not completed by a GOVERNMENT ENTITY)

10. Law Enforcement Notification (See instruction 2g)

Each applicant is to provide notification of the proposed making and possession of the firearm described on this Form 1 by providing a copy of the completed form to the chief

law enforcement officer in the agency identified below:

Agency or Department Name

Name and Title of Official

Address (Street address or P.O. Box, City, State and Zip Code) to which sent (mailed or delivered)

Information for the Chief Law Enforcement Officer

This form provides notification of the applicant's intent to make and register a National Firearms Act (NFA) firearm. No action on your part is required. However, should you

have information that may disqualify this person from making or possessing a firearm, please contact the NFA Branch at (304) 616-4500 or NFA@atf.gov. A "Yes" answer to

items 11.a through 11.h or 13.b or 13.c could disqualify a person from acquiring or possessing a firearm. Also, ATF will not approve an application if the making or possession of

the firearm is in violation of State or local law.

Maker's Questions (complete only when the maker is an individual)

A maker who is an individual must complete this Section.

11. Answer questions 11.a. through 11.h. Answer questions 13 and 14, if applicable. For any "Yes" answer the applicant shall provide details on a separate sheet. (See

instruction 7c and definitions)

Yes

12. Photograph

a. Are you under indictment or information in any court for a felony, or any other crime, for which the judge

could imprison you for more than one year? (See definition 1n)

b. Have you ever been convicted in any court for a felony, or any other crime, for which the judge could have imprisoned you

for more than one year, even if you received a shorter sentence including probation?

(See definition 1n)

c. Are you a fugitive from justice? (See definition 1t)

Affix

Recent Photograph Here

d. Are you an unlawful user of, or addicted to, marijuana or any depressant, stimulant, narcotic drug, or any other

(Approximately 2" x 2")

controlled substance? Warning: The use or possession of marijuana remains unlawful under Federal law

(See instruction 2e)

regardless of whether it has been legalized or decriminalized for medicinal or recreational purposes in

the state where you reside.

e. Have you ever been adjudicated as a mental defective OR have you ever been committed to a mental

institution? (See definition 1o and 1p)

f. Have you been discharged from the Armed Forces under dishonorable conditions?

g. Are you subject to a court order restraining you from harassing, stalking, or threatening your child or an

intimate partner or child of such a partner? (See definition 1q)

h. Have you ever been convicted in any court of a misdemeanor crime of domestic violence? (See definition 1r)

13a. Country of Citizenship: (Check/List more than one, if applicable. Nationals of the United States may check U.S.A.) (See definition 1s)

United States of America

Other Country/Countries (specify):

Yes No

b. Have you ever renounced your United States citizenship?

c. Are you an alien illegally or unlawfully in the United States?

d.1. Are you an alien who has been admitted to the United States under a nonimmigrant visa?

d.2. If "yes", do you fall within any of the exceptions stated in the instructions? Attach the documentation to the application

N/A

14. If you are an alien, record your U.S.-Issued Alien or Admission number (AR#, USCIS#, or 194#):

CERTIFICATION: Under penalties imposed by 18 U.S.C. § 924 and 26 U.S.C. § 5861, I certify that, upon submission of this form to ATF, a completed copy of this

form will be directed to the chief law enforcement officer (CLEO) shown in item 10, that the statements, as applicable, contained in this certification, and any attached

documents in support thereof, are true and correct to the best of my knowledge and belief. NOTE: See instructions 2.d(2) and 2.d(3) for the items to be completed

depending on the type of applicant.

Signature of Maker

Date

ATF E-Form 1 (5320.1)

ATF Copy 2 - To Be Returned to Registrant

Revised May 2016