State of PA recompete____Exhibit 5

Exhibit 5 Lautenberg Amendment Certification

CONTRACTOR EMPLOYEE INFORMATION

Name

Last First Middle

Contractor Contract #

PART I: INQUIRY

Yes

No

Initial

Date

Have you ever been convicted of a misdemeanor crime of domestic violence within the meaning of the statute?

If you answered “No”, skip to PART II of the form. If you answered “Yes”, review the attached information on the Lautenberg Amendment and then provide the information requested below and complete PART II of the form.

Court/Jurisdiction

Docket/Case Number

Statute/Charge

Date Sentenced

PART II: CERTIFICATION

I hereby certify that, to the best of my knowledge and belief, all of the information provided by me is true, correct, and complete, and made in good faith. I understand that a false statement on any part of this inquiry may be grounds for not hiring me or for firing me after I begin work. False or fraudulent information provided herein is also criminally punishable pursuant to federal law, including 18 U.S.C. 1001.

Signature

Date

Social Security Number

Privacy Statement

Authority and Purpose: FPS is collecting this information to assess your eligibility to possess or receive firearms or ammunition as an FPS law enforcement officer. Collection of this information is necessary to ensure FPS complies with 18 U.S.C. § 922(g)(9), which prohibits individuals convicted in any court of a misdemeanor crime of domestic violence from possessing a firearm or ammunition that has been shipped or transported in interstate or foreign commerce. The last four digits of your Social Security Number are requested in order to identify you and ensure that this form is maintained in the correct personnel file. The authority for collection of this information is 18 U.S.C. § 922.

Disclosure: Furnishing this information is mandatory. For current law enforcement officers, failure to provide this information will result in loss of eligibility to carry a firearm and may result in disciplinary action up to and including removal from a law enforcement officer position.

Routine Uses: This information will be used within FPS to confirm that current law enforcement officers are not b

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