Date:

Officer's Name:
Officer's Home Address
      *ATF regulations require letter must have officer's home address on letter*

I, hereby, certify under penalty of perjury, the above named law enforcement officer will use the requested firearm and/or large capacity ammunition feeding devices for use in performing official duties and that the firearm and/or large capacity ammunition feeding devices are not being acquired for personal use or for purposes of transfer or resale.

I, further certify under penalty of perjury, this individual does not have any convictions for crimes of violence, has not been convicted of any crime for which the penalty could be longer than one year, regardless of the sentence imposed. Furthermore, I certify that he/she is not subject to any restraining order restraining him/her from harassing, stalking or threatening an intimate partner or child of such a partner, and that has not been convicted in any court of a crime of domestic violence.

Signature of Purchaser
Signature of person of authority within agency

List Manufacturer, and model of weapon desired
List Manufacturer, model, and quantity of magazines desired