I hereby solemnly swear that I am not a person prohibited from possessing firearms, high capacity magazines, or ammunition, pursuant to Illinois Revised Statues, 1995, 720ILCS 5/24-1 thru 5/24-7, and/or the Violent Crime Control and Law Enforcement Act of 1994, and that I have not been a patient in a mental hospital within the past five years. I declare under penalty of perjury the information contained in this statement is true and accurate.
I further certify, under penalty of perjury, that we have done a background check and this individual does not have any convictions for the crimes of violence, has not been convicted of any crime for which their penalty could have been longer than one year, regardless of actual sentence imposed, that he/she is not subject to any restraining order restraining him/her from harassing, stalking or threatening an intimate partner or child of such a partner, and, that he/she has not been convicted in any court of a misdemeanor crime of domestic violence.
Signature of acquiring officer
Under penalty of perjury, I certify that
Star / ID Number ________________________________________________ is currently employed as a peace officer with ____________________________________________. The firearm, magazine, or ammunition described herein is intended for use by the acquiring officer in the performance of his/her official duties and the items acquired are not for the purpose of resale. This certification is valid for 60 days from the date of issuance.
Description of firearm:_________________________________________________________
Description of magazine:_______________________________________________________
Signature of Chief Administrator:_________________________________________________
Title / Rank:______________________________________ Date: ______________________
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Must be on department letterhead.