Chest. Cnty. Ct. Comm. Plea. R., form 1
See CCRCP 1901.7.A.(b)(3) as req'd by 23 Pa.C.S. 6108.1 & CCRCP 1901.7.A.
Protection Order Number: _____________________________
THE COUNTY OF CHESTER, OFFICE OF THE SHERIFF
201 W. Market Street, Suite 1201
P.O. Box 2746
West Chester, PA 19382-0989
FIREARM RELEASE REQUEST
A. REQUESTED INFORMATION :
____________________________________________________________________
LAST NAMEFIRST NAMEMIDDLE INITIALSUFFIX
____________________________________________________________________
ADDRESSCITYSTATEZIP CODE
____________________________________________________________________
DATE OF BIRTH (MM/DD/YYYY)SOCIAL SECURITY #RACESEX
____________________________________________________________________
DRIVER LICENSE #STATE OF ISSUANCE
____________________________________________________________________
HOME PHONE #MOBILE/CELL PHONE #EMAIL ADDRESS
*Please note that this process may take up to fifteen (15) days to complete. If your Firearms Release Request is denied, you have the right to petition the Court pursuant to 18 Pa. C.S. § 6105.1.
B. ACKNOWLEDGEMENT OF RETURN (Sign in the presence of Law Enforcement Officer/Designee) By signing below, I am confirming that if the request is approved, I am taking possession of the firearm(s), other weapon(s), and/or ammunition referenced in the above Protection Order Number and that they are in the same condition as when they were relinquished. I agree I will not hold the Department or Agency identified below liable for any damage or reduction in value of the firearm(s), other weapon(s), or ammunition.
I also certify that I am not prohibited by state or federal law from possessing of a firearm for any reason. I understand that no relinquished item will be returned to me unless I successfully pass a background check via the Pennsylvania Instant Check System (PICS) or National Instant Check System (NICS) check or comparable check in the state of my residence.
Requestor Signature: ________________ Date: _____________
Returning Officer/Designee signs below:
Officer/Designee Signature: _______________ Date: ______________
C. DEPARTMENT/AGENCY USE ONLY:
CHESTER CO. SHERIFF's OFFICE PHONE #: ___________________________ ORI: ___________
STREET ADDRESS ____________ CITY:
STATE: ZIP CODE:
PROCESSING DEPUTY/DESIGNEE NAME: __________________________ DATE: ____________
PROTECTION ORDER NO.: _______________ DATE ORDER ISSUED (Attach copy): _____________
DATE ORDER CANCELED/EXPIRED ________________
DATE RELINQUISHED: _____________ DEPARTMENT/INCIDENT/CASE NO.: ____________
DEFENDANT OTHERWISE PROHIBITED? [] YES [] NO
PICS CHECK CONDUCTED? [] YES [] NO PICS NO: ___________
FIREARM RETURNED? [] YES [] NO
If NO, explain in comments*
RECIEPT PROVIDED [] YES [] NO
FIREARMS EVIDENCE IN A CRIME? [] YES [] NO
PARTI AL RETURN? [] YES [] NO
If YES, explain in comments*
PLAINTIFF NOTIFIED? [] YES [] NO
If YES, attach copy of Certificate of Service indicating that at least 14 days have passed since request
DATE PLAINTIFF NOTIFIED: ___________________________________
METHOD OF NOTIFICATION: ___________________________________
DISTRICT ATTORNEY NOTIFIED? [] YES [] NO
If YES, attach copy of Certificate of Service indicating that at least 14 days have passed since request
DATE DISTRICT ATTORNEY NOTIFIED: ______________________________
METHOD OF NOTIFICATION: _____________________________________________
COMMENTS: _________________________________________
Chest. Cnty. Ct. Comm. Plea. R., form 1