HomeMy WebLinkAboutM16 Rifle Transfer Forms from Cottage Grove PD 2007 U.S. Department of Justice OMB No. 1140 -0015 (10/31/2007)
Bureau of Alcohol, Tobacco, Firearms and Explosives Application for Tax Exempt Transfer and
Registration of Firearm
SUBMIT in DUPLICATE to: National Firearms Act Branch
Bureau of Alcohol, Tobacco, Firearms and Explosives, 244 Needy Road, Martinsburg, WV 25401
2a. T ansf e's Name and A ncludfn trad ame, i any)(See instruction 2) 1. Type of Transfer: Tax Exempt I Believe That I
,¢ r V jr� am Entitled to Exemption From the Payment of the
• Q „J Transfer Tax Imposed By Section 5811 (26 U.S.C.
a O
Chapter 53) on the Firearm Described Herein for
4` �5 S5 2b. County the Following Reason (See Instruction 2b):
1 Firearm is Unserviceable and is Being
o n Transferred as a Curio or Ornament ❑
3a. Transferor's Name and d ar ess (Including tradenam
t e 6l ore. if any) (xecut s: see instruction 2j.)
Go ro l l(t &( ` Firearm is Being Transferred to or from a
Government Entity
Z76 " F f l
� 0"' �' / Firearm is Being Transferred to a Lawful Heir El
Irk IV, I Yl ,5� 1 •3b. Tran Telephone Number and Area Code
65t — 58 08 Other (Specify) ❑
3c. Number, Street, City, State and Zip Code of Residence (or firearms 3d. If Applicable: Decedent's Name and Address
Business Premises) If Different from Item 3a.
V J /yL [ Te.If Applicable: Decedent's Date of Death
/ /J 08-
above -named and undersigned transferor hereby makes application as required by Section 5812 of the National Firearms Act to transfer and register
the firearm described below to the transferee.
4. Description of Firearm (Complete items a through i)
a. Name and Address of anufacturer and/or Importer of Firearm b. Type of Firearm (See instruction 1 c) c. Caliber, Gauge or Size (Spec fy)
(� tiva�i ic�t Co. rh -I 7:�(� ��-►
R 0. Ax '
d. Model e. S 'al Number
w -fford Cr �G q_311
80 3 el-
f Length of Barrel (Inches) g. Overall Length (Inches) h. Additional Description or Data Appearing on Firearm (Attach additional sheet if necessary)
ls� 0 t/
i. Is the Firearm Unserviceable as Defined in Instruction 11? Yes ❑ No (7f 'No, "describe any other method by which firearms has been
rendered unserviceable. Use additional sheets)
5. Transferee's Federal Firearms License (If any) (Give complete 15 -digit 6. Transferee's Special (Occupational) Tax Status (If any)
number) (See instruction 2c) /V/ a. Employer IIdentification Number b. Classyg�
(" t/
7. Transferor's Federal Firearms License (If any) (Give complete 15 -digit 8. Transferor's Special (Occupational) Tax Status (If any)
number) (See instruction 2c) a. Employer Identification Number b. Class
Under Penalties of Perjury, I Declare that I have examined this application, and to the best of my knowledge and belief it is true, correct and complete,
and that the transfer of the described firearm to the transferee and receipt and possession of it by the transferee are not prohibited by the provisions of
Chapter 44, Title 18, United States Code; Chapter 53, Title 26, United States Code; or Title VII of the Omnibus Crime Control and Safe Streets Act, as
amended; or any pro of S or lo cal l aw.
9. •Consen't tb Disclosure of information to Transferee (See instruction 8). I Do or Do Not Authorize ATF to Provide Information Relating to this
Application to the Above -Named Transferee. I Do I Do Not ❑
10. Signature of T feror (or a officia { l) ) > 11. Name and Title of Authorized Official (Prin or Typ 12. / Date yj
The Space Below is for the of the Bureau or Alcohol, Tobacco, Firearms and Explosives
By Authority of The Director, This Application Has Be6Axamined, and the Transfer and Registration of the Firearm Described Herein and the Interstate
Movement of that Firearm, When Applicable, to the Transferee are:
Approved ( the foll co nditi o ns, ifany) ❑ Disapproved (For the following reasons) ❑
Condition/Reason
Signature of Authorized ATF Official Date
ATF E -Form 5 (5320.5)
Revised November 2004
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 No
a. Charged by information or under indictment in any court for a crime a. Been convicted in any court of a crime for which the judge could have
punishable by imprisonment for a term exceeding one year? 11 ❑ imprisoned you for more than one year, even if the judge actually gave El El
you a shorter sentence?
b. A fugitive from justice? ❑ ❑ b. Been discharged from the armed forces under dishonorable conditions? ❑ El
c. An alien who is illegally or unlawfully in the United ❑ ❑ c. Been adjudicated mentally defective or been committed to a mental ❑ ❑
States? institution?
d. Under 21 years of age? , ❑ ❑ d. Renounced your United States citizenship? ❑ ❑
e. An unlawful user of or addicted to, marijuana, or any depressant, e. Been convicted in any court of a misdemeanor crime of domestic
stimulant, or narcotic drug, or any other controlled substance? ❑ ❑ violence? This includes any misdemeanor conviction involving the use
or attempted use of physical force committed by a current or former ❑ ❑
f Subject to a court order restraining you from harassing, stalking, or M r spouse, parent, or guardian of the victim, or by a person with a similar
threatening an intimate partner or child of such partner? 1J 1J 1 relationship with the victim.
15. Transferee's Certification (See instruction 2e) 16. Photograph
I )00 li , have reasonable necessity to possess the
(Name of Transferee)
machinegun, short- barreled rifle, short- barreled shotgun, or destructive device described on this application for the
-following reason(s)
Affix
Recent Photograph Here
r 2 (Approximately 2" x 2 ")
and my possession of the device or weapon ould belconsistent with public safety (18 U.S.C. 922(b)(4) and 27 (See instruction 2i.)
CFR 478.98).
U R PENALTIES OF PERdLTRY, I declare that I have examined this application and the documents
ub i ed ' upport thereof, to the best of mx knowledge and belief it is true, correct and complete.
( Signature of Transferee) (Date)
17. Law Enforcement Certification (See instruction 2j)
I certify that I am t he chief law enforcement o�f'fi^ cer of the organization named below having jurisdiction in the area of residence of
hk e' A rP N `" i*�? tfave no information indicating that the transferee will use the firearm or device described
(Na e of ransferee)
0 n " 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
lac le transferee vi atio tate or local law.
d o ol
I t. Signature and Title of Chief Law Enforcement Officer) (Date)
�7 P vt ° p &T 7 4 Qq
(Organization and Street Address
q_3 �7� 3
(County) (elephone 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, Firearms and Explosives, 244 Needy Road, Martinsburg, WV 25401.
Change of Address: Unless currently licensed under the Gun Control Act, the registrant shall notify the NFA Branch, Bureau of Alcohol, Tobacco, Firearms and Explosives, 244 Needy
Road, Martinsburg, WV 25401, 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, Firearms and Explosives, 244 Needy Road, Martinsburg, WV 25401, in
writing, of any change to the description of the firearm(s) 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, Firearms and Explosives, 244 Needy Road, Martinsburg, WV 25401, in writing, immediately upon becoming prohibited for guidance wt the disposal ofthe 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 E -Form 5 (5320.5)
Revised November 2004
OMB No. 1140 -0015 (10/31/2007)
U.S. Department of Justice
Bureau of Alcohol, Tobacco, Firearms and Explosives Application for Tax Exempt Transfer and
Reg istration of Firearm
SUBMIT in DUPLICATE to: National Firearms Act Branch
Bureau of Alcohol, Tobacco, Firearms and Explosives, 244 Needy Road, Martinsburg, WV 25401
2 ransf e's Name and ress In ludin trad ame, i any)(See instruction 2) 1. Type of Transfer: Tax Exempt I Believe That I
r am Entitled to Exemption From the Payment of the
r-�
7 Transfer Tax Imposed By Section 5811 (26 U.S.C.
p a p� 9 !
0 Chapter 53) on the Firearm Described Herein for
y �� K 1 , 1 #5 ��� 2b. County the Following Reason (See Instruction 2b):
l * 1 1 Firearm is Unserviceable and is Being
t � � Transferred as a Curio or Ornament ❑
3a. Transferor's Name and d ess (Including tradenam if any) (xecut s: see instruction 2j.) Firearm is Being Transferred to or from a
e- & 00 lic r s'9 Government Entity
j (, �' _ / Firearm is Being Transferred to a Lawful Heir
C �
r,-*. 4_1 1 A / 3b. Transferor's Telephone Number and Area Code
Other (Specify) ❑ .
3c. Number, Street, City, State and Zip Code of Residence (or firearms 3d. If Applicable: Decedent's Name and Address
Business Premises) If Different from Item 3a.
3e. If WOff Decedent's Date of Death
f �f
The above -named and undersigned transferor hereby makes application as required by Section 5812 of the National Firearms Act to transfer and register
the firearm described below to the transferee.
4. Description of Firearm (Complete items a through i)
a. Name and Address of Manufacturer and/or Importer of Firearm b. Type of Firearm (See instruction 1 c) c. Caliber, Gauge or Size (Specify)
, 0 - bak -, YJ d. Model e. Serial Number e�
c6le" —0-8 1 V
�b
f. Length of Barrel (Inches) g. Overall L i gth (Inches) h. Additional Description or Data Appearing on Firearm (Attach additional sheet if necessary)
ao 'No, "describe an other method b which rearms has been
i. Is the Firearm Unserviceable as Defined in Instruction 11. Yes No �•f y y f
❑ B rendered unserviceable. Use additional sheets.)
5. Transferee's Federal Firearms License (If any) (Give complete 15 -digit 6. Transferee's Special (Occupational) Tax Status (If any)
number) (See instruction 2c) a. Employer Identification Number b. Class
All /7
7. Transferors Federal Firearms License (If any) (Give complete 15 -digit 8. Transferor's Special (Occupational) Tax Status (If any)
number) (See instruction 2c) a. Employer Identification Number b. Class
Under Penalties of Perjury, I Declare that l have examined this application, and to the best of my knowledge and belief it is true, &orrect and complete,
and that the transfer of the described firearm to the transferee and receipt and possession of it by the transferee are not prohibited by the provisions of
Chapter 44, Title 18, United States Code; Chapter 53, Title 26, United States Code; or Title VII of the Omnibus Crime Control and Safe Streets Act, as
amended; or any provisions of State or local law.
9. Consent to Disclosure of information to Transferee (See instruction 8). I Do or Do Not Authorize ATF to Provide Information Relating to this
Application to the Above -Named Transferee. I Do I Do Not ❑
10. Signature of Transferor (or authorized official) 11. Name and Title of Authorized Official (Print or Type) 112. Date
The Space Below is for use of the Bureau of` Icohol, Tobacco, Firearms and Explosives
By Authority of The Director, This Application Has 5cen Examined, and the Transfer and Registration of the Firearm Described Herein and the Interstate
Movement of that Firearm, When Applicable, to the Transferee are:
Approved (with the following conditions, if any) ❑ Dis approved (For the following reasons) ❑
Condition/Reason
Signature of Authorized ATF Official Date
ATF E -Form 5 (5320.5)
Revised November 2004
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 No
a. Charged by information or under indictment in any court for a crime a. Been convicted in any court of a crime for which the judge could have
punishable by imprisonment for a term exceeding one year? El El imprisoned you for more than one year, even if the judge actually gave ❑ ❑
you a shorter sentence?
b. A fugitive from justice? F� ❑ b. Been discharged from the armed forces under dishonorable conditions? ❑ ❑
c. An alien who is illegally or unlawfully in the United ❑ El c. Been adjudicated mentally defective or been committed to a mental ❑ ❑
States? institution?
d. Under 21 years of age? , ❑ ❑ d. Renounced your United States citizenship? ❑ ❑
e. An unlawful user of or addicted to, marijuana, or any depressant, e. Been convicted in any court of a misdemeanor crime of domestic
stimulant, or narcotic drug, or any other controlled substance? ❑ ❑ violence? This includes any misdemeanor conviction involving the use
or attempted use of physical force committed by a current or former ❑ ❑
f Subject to a court order restraining you from harassing, stalking, or m spouse, parent, or guardian of the victim, or by a person with a similar
threatening an intimate partner or child of such partner? tJ ❑ relationship with the victim.
15. Transferee's Certification (See instruction 2e) 16. Photograph
I, have reasonable necessity to possess the
(Name of Transferee)
machinegun, short- barreled rifle, short- barreled shotgun, or destructive device described on this application for the
-following reason(s)
Affix
Recent Photograph Here
r 2 (Approximately 2" x 2 ")
and my possessiorf of the device or weapon ould belconsisteni with public safety (18 U.S.C. 922(b)(4) and 27 (See instruction 2i.)
CFR 478.98).
U R PENALTIES OF PERJURY, I declare that I have examined this application and the documents
s mit ed n,support there ,.knd to the best of m knowledge and belief it is true, correct and complete.
� 1
2 c`
(Signature of Transferee) (Date)
17. Law Enforcement Certification (See instruction 2,f)
I certify that I am� h
the chief law enforcement o� of the `` organization named below having jurisdiction in the area of residence of
"ir ��fi ��'" F'�& no information indicating that the transferee will use the firearm or device described
(Name of ransferee)
on is a plication 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
pla e th tr feree in violatio State or local law.
ignature and Title of Chief Law Enforcement Officer) (Date)
Red Pk ,ter P "6.ru- 7 , 04L Rh & M6
(Organization and Street Address
(County) (elephone 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, Firearms and Explosives, 244 Needy Road, Martinsburg, WV 25401.
Change of Address: Unless currently licensed under the Gun Control Act, the registrant shalt notify the NFA Branch, Bureau of Alcohol, Tobacco, Firearms and Explosives, 244 Needy
Road, Martinsburg, WV 25401, 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, Firearms and Explosives, 244 Needy Road, Martinsburg, WV 25401, in
writing, of any change to the description of the firearm(s) 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, Firearms and Explosives, 244 Needy Road, Martinsburg, WV 25401, in writing, immediately upon becoming prohibited 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 E -Form 5 (5320.5)
Revised November 2004
U.S. Department of Justice OMB No. 1140 -0015 (10/3112007)
Bureau of Alcohol, Tobacco, Firearms and Explosives Application for Tax Exempt Transfer and
Registration of Firearm
SUBMIT in DUPLICATE to: National Firearms Act Branch
Bureau of Alcohol, Tobacco, Firearms and Explosives, 244 Needy Road, Martinsburg, WV 25401
2a. T sf e's Name and A40ress Includin tradepame, i any)(See instruction 2) 1. Type of Transfer: Tax Exempt I Believe That I
may, rV— p.i f iC� i16'n a, am Entitled to Exemption From the Payment of the
7 Transfer Tax Imposed By Section 5811 (26 U.S.C.
Q
V / Chapter 53) on the Firearm Described Herein for
0 ap �q( 1 #5 f 650s) 2b. County the Following Reason (See Instruction 2b):
Firearm is Unserviceable and is Being
3a. Transferor's Name and d ess (Including tradenam if any) (xecut s: see instruction 2j.) Transferred as a Curio or Ornament
(� Firearm is Being Transferred to or from a
�� �(,� Q ICS fr�-1t�7 Government Entity
t� ' ft ( Firearm is Being Transferred to a Lawful Heir ❑
t � l 3b. Transferor's Telephone Number and Area Code
5� Other (Specify) El
3c. Number, Street, City, State and Zip Code of Residence (or firearms 3d. If Applicable: Decedent's Name and Address
Business Premises) If Different from Item 3a.
+�'
� `K [ 5e. If Applicable: Decedent's Date of Death
(� 0
The above -named and undersigned transferor hereby makes application as required by Section 5812 of the National Firearms Act to transfer and register
the firearm described below to the transferee.
4. Description of Firearm (Complete items a through i)
a. Name and Address of Manufacturer and/or Importer of Firearm b. Type of Firearm (See instruction 1c) c. Caliber, Gauge or Size (Spec)
R o btu( 16 d. Model e. Serial u ber
f. Length o fBa (Inches) g. Overall Length (Inches) h. Additional Description or Data Appearing on Firearm (Attach additional sheet if necessary) it
!,� � !/
i. Is the Firearm Unserviceable as Defined in Instruction 11? No (7 "describe any other method by which firearms has been
Yes
❑ rendered unserviceable. Use additional sheets)
5. Transferee's Federal Firearms License (If any) (Give complete 15 -digit 6. Transferee's Special (Occupational) Tax Status (Ifany)
number) (See instruction 2c) a. Employer Identification Number b. Class
/V/
7. Transferor's Federal Firearms License (If any) (Give complete 15 -digit 8. Transferor's Special (Occupational) Tax Status (If any)
number) (See instruction 2c) pe} . a. Employer Identification Number b. Class
`I I tL/
Under Penalties of Perjury, I Declare that I have examined this application, and to thebest of my knowledge and belief it is true, correct and complete,
and that the transfer of the described firearm to the transferee and receipt and possession of it by the transferee are not prohibited by the provisions of
Chapter 44, Title 18, United States Code; Chapter 53, Title 26, United States Code; or Title VII of the Omnibus Crime Control and Safe Streets Act, as
amende or any prov of State or local law.
9. •Conserit to Disclosure of information to Transferee (See instruction 8). 1 Do or Do Authorize ATF to Provide Information Relating to this
Application to the Above -Named Transferee. I Do I Do Not ❑
10. Signature of T sferor (or authorized off cia 11. Name and Title of Authorized Official (Print or Type) 12. / Date
u The Space Below is f e use of the Bureau Tobacco, Firearms and Explosives
By Authority of The Director, This Application H Been Examined, and the Transfer and Registration of the Firearm Described Herein and the Interstate
Movement of that Firearm, When Applicable, to the Transferee are:
Approved (with the f o l lowing conditions, i f any) Disapproved (For the following reasons)
Condition/Reason
Signature of Authorized ATF Official Date
ATF E -Foam 5 (5320.5)
Revised November 2004
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 No
a. Charged by information or under indictment in any court for a crime a. Been convicted in any court of a crime for which the judge could have
punishable by imprisonment for a term exceeding one year? El El imprisoned you for more than one year, even if the judge actually gave El El
you a shorter sentence?
b. A fugitive from justice? ❑ ❑ b. Been discharged from the armed forces under dishonorable conditions? ❑ ❑
c. An alien who is illegally or unlawfully in the United ❑ ❑ c. Been adjudicated mentally defective or been committed to a mental ❑ ❑
States? institution?
d. Under 21 years of age? , El d. Renounced your United States citizenship? El El
e. An unlawful user of or addicted to, marijuana, or any depressant, e. Been convicted in any court of a misdemeanor crime of domestic
stimulant, or narcotic drug, or any other controlled substance? El El violence? This includes any misdemeanor conviction involving the use 11 El
attempted use of physical force committed by a current or former
f Subject to a court order restraining you from harassing, stalking, or n !� spouse, parent, or guardian of the victim, or by a person with a similar
threatening an intimate partner or child of such partner? I__i relationship with the victim.
15. Transferee's Certification (See instruction 2e) 16. Photograph
I, ! , have reasonable necessity to possess the
(Name of Transferee)
machinegun, short - barreled rifle, short- barreled shotgun, or destructive device described on this application for the
-following reason(s) Affix
Recent Photograph Here
fo r 2 (Approximately 2" x 2 ")
and my possession of the device or weapon ould belconsisteni with public safety (18 U.S.C. 922(b)(4) and 27 (See instruction 2i.)
CFR 478.98).
UND PENALTIES OF PERJURY, I declare that I have examined this application and the documents
ub tte in port thereof, and the best of m knowledge and belief it is true, correct and complete.
r c.
ignature of Transferee) (Date)
17. Law Enforcement Certification (See instruction 2jg
I certify that I am the he chief law enforcement officer of the organization named below having jurisdiction in the area of residence of
h Z r ah I pp � ke t � � `_I Have no information indicating that the transferee will use the firearm or device described
(Na*e of rnsferee)
on thi plication 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
!ac transferee in violation of tate or local law.
s c
ignaturd and Title of Chief Law Enforcement Officer) (Date)
i $ / i� ,, h
(Organization and Street Address
(County) (elephone 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, Firearms and Explosives, 244 Needy Road, Martinsburg, WV 25401.
Change of Address: Unless currently licensed under the Gun Control Act, the registrant shall notify the NFA Branch, Bureau of Alcohol, Tobacco, Firearms and Explosives, 244 Needy
Road, Martinsburg, WV 25401, in writing, of any change to the address in Item 2i.
Change of Description: The registrant shall notify the NFA Branch, Bureau of Alcohol, Tobacco, Firearms and Explosives, 244 Needy Road, Martinsburg, WV 25401, in
writing, of any change to the description of the firearm(s) 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 maybe 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, Firearms and Explosives, 244 Needy Road, Martinsburg, WV 25401, in writing, immediately upon becoming prohibited 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 E -Form 5 (5320.5)
Revised November 2004
U.S. Department of Justice OMB No. 1140 -0015 (10/31/2007)
Bureau of Alcohol, Tobacco, Firearms and Explosives Application for Tax Exempt Transfer and
Registration of Firearm
SUBMIT in DUPLICATE to: National Firearms Act Branch
Bureau of Alcohol, Tobacco, Firearms and Explosives, 244 Needy Road, Martinsburg, WV 25401
2a T f e's Name and A ncludinz tradename, if any) (See instruction 2) 1. Type of Transfer: Tax Exempt I Believe That I
(� j Al- pff fl'!P'f am Entitled to Exemption From the Payment of the
�j 7 v Transfer Tax Imposed By Section 5811 (26 U.S.C.
d� } f,� Chapter 53) on the Firearm Described Herein for
/
r � �5V 8 2b. County the Following Reason (See Instruction 2b):
1
11a� hl'aq l o n Firearm is Unserviceable and is Being
3a Transferors Name and d ess (Includingtradenam ifany) (xecut s: see instruction 2j.) Transferred as a Curio or Ornament
� V jr e - `� Firearm is Being Transferred to or from a
7�6 &0 S1S Government Entity
� / ����`/ Firearm is Being Transferred to a Lawful Heir
C Q 1 t ✓ LF 3b. Transferor's Telephone Number and Area Code
Other (Sped) El
3c. Number, Street, City, State and Zip Code of Residence (or firearms 3d Decedent's Name and Address
Business Premises) If Different from Item 3a.
V O n 1/ 3e. If Applicable: Decedent's Date of Death
The above -named and undersigned transferor hereby makes application as required by Section 5812 of the National Firearms Act to transfer and register
the firearm described below to the transferee.
4. Description of Firearm (Complete items a through o
a. Name and Address of Vanufacturer and/or Importer of Firearm b. Type of Firearm (See instruction 1c) c. Caliber, Gauge or Size (Spec)
Co. l p '' l �I.'
° &N lb
d. Model e. erial Number
Or
f. Length of Barrel (Inches) 1 g. Overall Length (Inches) h Additional Description or Data Appearing on Firearm (Attach additional sheet if necessary)
t r� !d tT
i. Is the Firearm Unserviceable as Defined in Instruction 11? I ❑ No (If "NO," e any other method by which firearms has been
rendered unserviceable. Use additional sheets.)
5. Transferee's Federal Firearms License (If any) (Give complete 15 -digit 6. Transferee's Special (Occupational) Tax Status (If any)
number) (See instruction 2c) a Employer Identification Number b. Class
7. Transferor's Federal Firearms License (If any) (Give complete 15 -digit 8. Transferor's Special (Occupational) Tax Status (If any)
number) (See instruction 2c) pe} . a. Employer Identification Number b. Class
Under Penalties of Perjury, I Declare that I have examined this application, and to the best of my knowledge and belief it is true, orrect and complete,
and that the transfer of the described firearm to the transferee and receipt and possession of it by the transferee are not prohibited by the provisions of
Chapter 44, Title 18, United States Code; Chapter 53, Title 26, United States Code; or Title VII of the Omnibus Crime Control and Safe Streets Act, as
amended; or any provisions of State or local law.
9. -Consent t6 Disclosure of Information to Transferee (See instruction 8). I Do or Da Not Authorize ATF to Provide Information Relating to this
Application to the Above -Named Transferee. I Do I Do Not
10. Signature of Trans 'ror (or authorized ` off / cia o 11. Name and Title of Authorized Official (Print or Type) 12. Date
The Space Below is for th a of the Bureau Of Alcohol, Tobacco, Firearms and Explosives
By Authority of The Director, This Application Has Ben Examined, and the Transfer and Registration of the Firearm Described Herein and the Interstate
Movement of that Firearm, When Applicable, to the Transferee are:
Approved (with the following conditi if any) F D isapproved (For the following reasons)
�ommtion/Reason
Signature of Authorized ATF Official Date
ATF E -Form 5 (5320.5)
Revised November 2004
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 No
a or under indictment in any court for a crime a. Been convicted in any court of a crime for which the judge could have
. Charged by information
punishable by imprisonment for a term exceeding one year?
❑ El imprisoned you for more than one year, even if the judge actually gave El
you a shorter sentence?
b. A fugitive from justice? ❑ ❑ b. Been discharged from the armed forces under dishonorable conditions? ❑ ❑
c. An alien who is illegally or unlawfully in the United ❑ ❑ c. Seen adjudicated mentally defective or been committed to a mental ❑ ❑
States? institution?
d. Under 21 years of age? . ❑ ❑ d. Renounced your United States citizenship? ❑ ❑
e. An unlawful user of or addicted to, marijuana, or any depressant, e. Been convicted in any court of a misdemeanor crime of domestic
stimulant, or narcotic drug, or any other controlled substance? El El violence? This includes any misdemeanor conviction involving the use
or attempted use of physical force committed by a current or former ❑ El f Subject to a court order restraining you from harassing, stalking, or n n spouse, pzrent, or guardian of the victim, or by a person with a similar
threatening an intimate partner or child of such pa u,0r? — relationship with the victim.
/�
i 15. Transferee's Certification (See instruction 2e) 16. Photograph
I, c 100 have reasonable necessity to possess the
(Name of Transferee)
machinegun, short- barreled rifle, short- barreled shotgun, or destructive device described on this application for the
,following reason(s) Affix
Recent Photograph Here
P (Approximately 2" x 2 ")
and my posscssiod of the device or weapon ould belconsisteni with public safety (18 U.S.C. 922(6)(4) and 27 (See instruction 2i.)
CFR 478.98).
UNDER PENALTIES OF PERJURY, I declare that I have examined this application and the documents
sus ttted m support thereof, and to the best of m knowledge and belief it is true, correct and complete.
(Signature of Transferee) (Date)
17. Law Enforcement Certification (See instruction 2,9
I certify that I am the chief law officer of the organization named below having jurisdiction in the area of residence of
rQ f P t1 Piave no information indicating that the transferee will use the firearm or device described
(.Na &'e of rnsferee)
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
la l e transferee in violation of State or local law.
k
(Signature and Title of Chief Law Enforcement Officer) (Date)
J (Organization and Street Address
(County) (elephone 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, Firearms and Explosives, 244 Needy Road, Martinsburg, WV 25401.
Change of Address: Unless currently licensed under the Gun Control Act, the registrant shall notify the NFA Branch, Bureau of Alcohol, Tobacco, Fireamis and Explosives, 244 Needy
Road, Martinsburg, WV 25401, in writing, of any change to the address in Item h
Change of Description: The registrant shall notify the NFA Branch, Bureau of Alcohol, Tobacco, Firearms and Explosives, 244 Needy Road, Martinsburg, WV 25401, in
writing, of any change to the description of the firearm(s) 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, Firearms and Explosives, 244 Needy Road, Martinsburg, WV 25401, in writing, immediately upon becoming prohibited 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 E -Form 5 (53205)
Revised November 2004
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 I No 14. Have You: Yes No
a. Charged by information or under indictment in any court for a crime a. Been convicted in any court of a crime for which the judge could have
punishable by imprisonment for a term exceeding one year? imprisoned you for more than one 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 conditions? ❑ ❑
c. An alien who is illegally or unlawfully in the United ❑ ❑ c. Been adjudicated mentally defective or been committed to a mental ❑ ❑
States? institupon?
d. Under 23 years of age? . ❑ ❑ d. Renounced your United States citizenship? 1:1 El
e. An unlawful user of or addicted to, marijuana, or any depressant, e. Been convicted in any court of a misdemeanor crime of domestic
stimulant, or narcotic drug, or any other controlled substance? F1 0 violence? This includes any misdemeanor conviction involving the use
or attempted use of physical force committed by a current or former ❑ ❑
f. Subject to a court order restraining you from harassing, stalking, or r-1 1 spouse, parent, or guardian of the victim, or by a person with a similar
threatening an intimate partner or child of such partner? i—' 1 L-' 1 relationship with the victim.
15. Transferee's Certification (See instruction 2e) 16. Photograph
I 1 1. ` G+>f� , have reasonable necessity to possess the
(Name of Transferee)
machinegun, short- barreled rifle, short- barreled shotgun, or destructive device described on this application for the
-following reason(s)
Affix
Recent Photograph Here
tq / 04 0 < ; P (Approximately 2" x 2")
and my possession of the device or weapon ould b consistent with public safety (18 U.S.C. 922(b)(4) and 27 (See instruction 2i.)
CFR 478.98).
T ER PENALTIES OF PERJURY, I declare that I have examined this application and the documents
tte d ' support thereof and to the best of m knowledge and belief it is true, correct and complete.
S
.(Signature of Transferee) (Date)
17. Law Enforc C ertification (See instruction 2,9
I certify that I am the chief law enforcement officer of�thhee named below having jurisdiction in the area of residence of
IT
Pf^ I� B `� � � ( I Have no information indicating that the transferee will use the firearm or device described
(Na e of ransferee)
o s 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
lace, the sferee in violation of State or local taw.
ti
n _-C
! ll�iln OT f3 1 C�
Signature and Title of Chief Law Enforcement Officer) (Date)
(Organization and Street Address
IA&I &I N- �3 �7�
(County) (elephone 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, Firearms and Explosives, 244 Needy Road, Martinsburg, WV 25401.
Change of Address: Unless currently licensed under the Gun Control Act, the registrant shall notify the NFA Branch, Bureau of Alcohol, Tobacco, Firearms and Explosives, 244 Needy
Road, Martinsburg, WV 25401, 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, Firearms and Explosives, 244 Needy Road, Martinsburg, WV 25401, in
writing, of any change to the description of the firearm(s) 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(ax4) 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, Firearms and Explosives, 244 Needy Road, Martinsburg, WV 25401, in writing, immediately upon becoming prohibited 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 E -Form, 5 (5320.5)
Revised November 2004
U.S. Department of Justice OMB No. 1140 -0015 (10/31/2007)
Bureau of Alcohol, Tobacco, Firearms and Explosives Application for Tax Exempt Transfer and
Registration of Firearm
SUBMIT in DUPLICATE to: National Firearms Act Branch
Bureau of Alcohol, Tobacco, Firearms and Explosives, 244 Needy Road, Martinsburg, WV 25401
2a. T sf e's Name and Afl ress In ludin trad ame, fany)(See instruction 2) 1. Type of Transfer: Tax Exempt I Believe That I
[`� rKG3i[E' ,I?�I'►v +� / / # , am Entitled to Exemption From the Payment of the
A
p � y (� Q�T Transfer Tax Imposed By Section 5811 (26 U.S.C.
V f Chapter 53) on the Firearm Described Herein for
�qs ' ��5� �5®s✓ Q � 2b. County the Following Reason (See Instruction 2b):
1 C n Firearm is Unserviceable and is Being El
3a. Transferor's Name and P djess (Including tradename,ifany) (xecut s: see instruction 2j.) Transferred as a Curio or Ornament
� PSG 2 ��� j��},i -,f -�? Firearm is Being Transferred to or from a
7,576 �� S� � Government Entity
� r � f � � T Firearm is Being Transferred to a Lawful Heir
t l 3b. Transferor's Telephone Number and Area Code
6 5 1 — V58 — 9,F50 Other (Sped)
3c. Number, Street, City, State and Zip Code of Residence (or firearms 3d. If Applicable: Decedent's Name and Address
Business Premises) If Different from Item 3a.
�
`K r ,, //� 3e. If Appli cable: Decedent's Date of Death
(� V rvl)9-
The above -named and undersigned transferor hereby makes application as required by Section 5812 of the National Firearms Act to transfer and register
the firearm describ be t the transferee.
4. Description of Firearm (Complete items a through i)
a. Name and Address of anufacturer and/or Importer of Firearm b. Type of Firearm (See instruction 1c) c. Caliber, Gauge or Size (Spec)
0. bm 669 d. Model e. Serial Number
f. Length of Barrel (Inches) g. Overall Length gth (Inches) h. Additional Description or Data Appearing on Firearm (Attach additional sheet i necessary)
. o 1
i. Is the Firearm Unserviceable as Defined in Instruction Il? Yes No (7f "No, "describe any other method by which firearms has been
rendered unserviceable. Use additional sheets.)
5. Transferee's Federal Firearms License (If any) (Give complete 15 -digit 6. Transferee's Special (Occupational) Tax Status (If any)
number) (See instruction 2c) a. Employer Identification Number b. Class
/V/�
7. Transferors Federal Firearms License (If any) (Give complete 15 -digit 8. Transferor's Special (Occupational) Tax Status (If any)
number) (See instruction 2c) a. Employer Identification Number b. Class
`I
Under Penalties of Perjury, I Declare that I have examined this application, and to the best of - my knowledge and belief it is true, orrect and complete,
and that the transfer of the described firearm to the transferee and receipt and possession of it by the transferee are not prohibited by the provisions of
Chapter 44, Title 18, United States Code; Chapter 53, Title 26, United States Code; or Title VII of the Omnibus Crime Control and Safe Streets Act, as
amended; or any provisions of State or local law.
9. -Consent to Disclosure of information to Transferee (See instruction 8). 1 Do or Do Authorize ATF to Provide Information Relating to this
Application to the Above -Named Transferee. I Do I Do Not
10. Signature 9f Transferor (or authorized official) 11. Name and Title of Authorized Official (Print or Type) 12. Date
The Space Belo fs for the use of the Bureau o f' Alcohol, Tobacco, Firearm and Explosiv
By Authority ofThe Director, This Applicatdn Has Been Examined, and the Transfer and Registration of the Firearm Described Herein and the Interstate
Movement of that Firearm, When Applicable, to the Transferee are:
App (w the f o ll owing condit if any) Di sappr o ved (For the following reasons)
Condition/Reason
Signature of Authorized ATF Official Date
ATF E -Form 5 (5320.5)
Revisers November 2004