Section_J_Attachment 13 - Lautenberg Amendment Statement.pdf
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- Solicitation number
- 70FBR427R00000001
About this file
This document is the Lautenberg Amendment Compliance Form issued by the U.S. Department of Homeland Security's Federal Emergency Management Agency (FEMA) for official use only.
The form requires individuals to certify their compliance with the Lautenberg Amendment to the Gun Control Act of 1968 (18 U.S.C. §922), which prohibits persons convicted of felonies or misdemeanor crimes of domestic violence from shipping, transporting, possessing, or receiving firearms or ammunition. The form defines misdemeanor crimes of domestic violence as those involving the use or attempted use of physical force, or threatened use of a deadly weapon, committed by current or former spouses, parents or guardians, persons sharing a child in common with the victim, persons cohabiting with the victim, or persons similarly situated to a spouse, parent, or guardian. Respondents must answer whether they have ever been convicted of any felony or misdemeanor crime of domestic violence, initial and date their response, and if answering affirmatively, provide detailed conviction information including court/jurisdiction, docket/case number, statute/charge, and date of sentence. The form includes a certification statement indicating that false or fraudulent information may result in disqualification from employment consideration, adverse action including removal, and criminal penalties under 18 USC 1001. Signatories must provide printed name, signature, title, and date.
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U.S. Department of Homeland Security
Washington, DC 20472 www.fema.gov
FOR OFFICIAL USE ONLY
Lautenberg Amendment Compliance Form
The Lautenberg Amendment to the Gun Control Act of 1968 (18 U.S.C. §922) makes it unlawful for any person who has been convicted of a misdemeanor crime of domestic violence to ship, transport, possess, or receive firearms or ammunition. This prohibition applies to persons convicted of such misdemeanors at any time.
A misdemeanor crime of domestic violence is defined as one that includes the use or attempted use of physical force, or the th1reatened use of a deadly weapon, committed by a current or former spouse, parent or guardian of the victim, by a person with whom the victim shares a child in common, by a person who is cohabiting with or has cohabited with the victim as a spouse, parent. or guardian, or by a person similarly situated to a spouse, parent or guardian of the victim.
1. Have you ever been convicted of any felony or a misdemeanor crime of domestic violence within the meaning of the Act?
Initial and date: _________ YES______ NO______
2. If you answer YES to the first question, provide the following information with respect to the conviction:
Court/Jurisdiction: ________________________________________________________
Docket/Case Number: ________________________________________________________
Statute/Charge: ________________________________________________________
Date of Sentence: ___________________________________________________________
I hereby certify that, to the best of my knowledge and belief, all the information provided by me is true, correct, complete, and made in good faith. I understand that false or fraudulent information provided may be grounds for disqualification from consideration for employment, or for adverse action, up to and including removal, and is also criminally punishable pursuant to federal law, including 18 USC 1001.
Printed Name Signature
Title Date
| Initial and date: |
| CourtJurisdiction: |
| DocketCase Number: |
| StatuteCharge: |
| Date of Sentence: |
| Printed Name: |
| Title: |
| YES: Off |
| NO: Off |
| DATE: |
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