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UNDER PENALTIES OF PERJURV, 1 DECLARE that 1 have examined this application, and to tha beat of my knowledge and belief it it true, correct and complete, and that tha l rentier of the deacrfbed firaarm to the transferee end receipt end paiiflcn of H by the transferee are not proWMtad by tha provisions of Chapter 44. Title IB. United S tatet Coda; Chapter S). TM» 2«. United S tatet Coda: or TWs VU of the Omrribut Crime Control and Safe Streeta Act. a» «mended, or any provision* of Slate or local law.

9. SIGNATURE OF TRANSFEROR (Or Mhoröed otfk&i

!0. NAME ANO TITLE OF AUTHORIZED OFFICIAL IPrint a mm/

tt. DATE

THE SPACE BELOW IS FOR THE USE OF THE BUREAU Of ALCOHOL. TOBACCO ANO FIREARMS

BY AUTHORITY OF THE DIRECTOR, THIS APPLICATION HAS BEEN EXAMINED, ANO THE TRANSFER AND REGISTRATION OF THE FIREARM DESCRIBED HEREIN ANO THE INTERSTATE MOVEMENT OF THAT FIREARM, WHEN APPLICABLE. TO THE TRANSFEREE ARE:

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