Attachment 13 Lautenberg Amendment Statement.pdf

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