Form UnNumbered NICS Firearm Disposition Record

OMB No. 1110-xxxx

Agency File Number ___________________

NICS Firearm Disposition Record
THIS FORM IS FOR LAW ENFORCEMENT USE ONLY AND IS NOT TO BE USED BY FEDERAL FIREARMS LICENSEES.
Use of this form is mandatory for auditing purposes. Please print. All entries should be in ink.
Read the Important Notices and Instructions on pages 3-6 of this form.

Before completing this form, please review the list of Federal Firearms Prohibitors on pages 5 and 6 of this form.
If you know an individual is prohibited from possessing a firearm, do not conduct a NICS background
check or transfer the firearm to that individual (Title 18, United States Code [U.S.C.], Section 922[d]).
Section A – To Be Completed Personally by Recipient (see Information for Completing Section A)
1

Recipient’s Full Name:
Last Name

2

Middle Name (if no middle name, enter “NMN”)

First Name

Current Residence Address (Cannot be a post office box.)

3

Street Address

Place of Birth:
U.S. City/State ___________________________________
-ORForeign Country __________________________________

City
4

County
State
5

Month

Zip Code
6

Height:

10a

_______ lbs.

Social Security Number (Optional, but may prevent misidentification.)
Ethnicity:

Are you Hispanic or Latino?
(See Information for Question 10[a].)
Yes
No

11

Day
7

Weight:

Feet _____ Inches _____
8

Date of Birth:

9

Year

Gender:
Male

Female

Unique Personal Identification Number (UPIN) if applicable
(See Instructions for Question 9.)

What is your state of residence (if any)? (See Information for Completing
Question 11.)
________________________________________________________

10b Race (Check one or more boxes. See information

for Question 10[b]))
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander

12

What is your country of citizenship? (List/check more than one if applicable.)
If you are a citizen of the United States, proceed to Question 17. If you are
not a citizen of the United States, check the box located beside “Other” and
write your country of citizenship in the space provided.
United States

Other (Specify) _______________________________

White
13

Are you an alien illegally in the United States?

Yes

No

14

Are you an alien admitted to the United States under a nonimmigrant visa? (See Information for Question 14.) If you
answered “No” to this question, you are not required to respond to question 15.

Yes

No

Yes

No

15

16

If you are an alien admitted to the United States under a nonimmigrant visa, do you fall within any of the exceptions set forth
under Information for Question 15? (If your answer is “Yes,” the official transferring the firearm must complete Question 20 (c).
(See information for Question 15.) If Question 14 is answered with a “No” response, then do NOT respond to this question.

If you are not a citizen of the United States, what is your U.S.-issued alien number or admission number? ___________________________

I certify the answers to Section A are true and correct. I am aware this form contains Important Notices, Information for Completing all Sections,
and definitions. I understand a person who answers “Yes” to Question 13 is prohibited from receiving a firearm. I understand that a person who
answers “Yes” to Question 14 is prohibited from receiving a firearm, unless the person also answers “Yes” to Question 15.
17

Recipient’s Signature

18

Certification Date

OMB No. 1110-xxxx

Section B – To Be Completed By Transferor (see Information for Completing Section B)
19

Type of transaction(s):

Handgun
Long Gun (rifles or shotguns)
Other (frame, receiver, etc. See instructions for Question 19)

20

(a) Identification (e.g., driver’s license or other valid government-issued photo identification). (See Information for Question 20[a].)
Issuing Authority and Type of
Number on Identification:
Expiration Date on Identification (if any):
Identification:
Month
Day
Year

20

(b) Alternate Documentation (if driver’s license or other identification document does not show current residence address) (See information
regarding Question 20.)

20

(c) Aliens admitted to the United States under a nonimmigrant visa must provide: Type of documentation showing an exception to
the nonimmigrant visa prohibition (e.g., valid state-issued hunting license or a letter from the U.S. Attorney General granting a waiver).
(See Instruction for Question 20[c].)

Question 21 (a) through (e) : Complete Prior to the Transfer of Firearm(s) (See Information for Completion of Question 21.)
21

(a)

Recipient’s identifying information in Section A was transmitted to the NICS/appropriate State Agency on:
Month

21

Day

Year

(b) NICS or State Transaction Number was:
_______________________

21

21

21

(c) Initial response provided by the NICS/appropriate State Agency:
Proceeded

Delayed (Firearm[s] should NOT be transferred on delayed transactions.)

Denied

Cancelled

(d) If initial NICS/State Agency response was “Delayed,” the following response was received from the NICS/appropriate State Agency:
Proceeded _____________ (date)

No resolution was provided.

Denied ______________ (date)

Cancelled ___________ (date)

(e) The name and Brady Identification number of the NICS Examiner (optional): ________________________/________________________
(name
Brady Identification Number)

Section C – To Be Completed by Transferor (see Information for Completing Section C)
22

Manufacturer and/or Importer

27

Miscellaneous Comments (For use by Transferor. See Information for Question 27) :

23

Model

24

Serial Number

25

Type (pistol, revolver,
rifle, shotgun, etc.)

26

Caliber or Gauge

Based on the statements in Section A, a review of the Federal Firearms Prohibitors (attached), and my verification of the identification noted in
Question 20(a), it is my belief it is not unlawful for me to transfer the firearm(s) associated with this form to the person identified in Section A as
the recipient.
Questions 28-31 – To Be Completed By The Transferor/Official Even If The Firearm Was Not Transferred.
28

Name of Transferor/Official (Please Print):
________________________________________________________

29

Signature of Transferor/Official:

30

Title of Transferor/Official (Please Print):

________________________________________________________________
___________________________________________________________

31

Date Transfer of Firearm is Completed:

________________________

OMB No. 1110-xxxx

Important Notices
Purpose of this Form: This form will be utilized by any criminal justice or law enforcement agency (transferor) for the disposition of firearms to a
recipient. The transferor must determine the lawfulness of the transfer and will keep proper records of it for NICS auditing purposes. Consequently,
the transferor must be familiar with the provisions of 18 U.S.C. 921-931 and the regulation in Title 27, Code of Federal Regulations (C.F.R.), Part
478.
Retention of this Form: After the transferor has completed the firearms transfer, he or she will make the completed, original Firearms Disposition
Record form (which includes the Important Notices and Information for Completing Sections A, B, and C) and any supporting documents part of the
agency’s records. FOR AUDIT PURPOSES, ALL FIREARM DISPOSITION RECORD FORMS MUST BE RETAINED FOR FIVE (5) YEARS,
REGARDLESS OF THE NICS DETERMINATION (PROCEEDED, DENIED, DELAYED OR CANCELLED) OR WHETHER THE FIREARM WAS
TRANSFERRED.
Changes to this Form: If the transferor or the recipient discovers a Firearm Disposition Record form is incomplete or improperly completed after the
firearm has been transferred, and the transferor or the recipient wishes to make a record of the error, photocopy the inaccurate form and make any
necessary additions or revisions on the photocopy. Only the recipient may make changes to Section A. The transferor may make changes only to
Sections B and C. All changes will be initialed and dated by the individual making the changes. The corrected photocopy will be attached to
the original Firearm Disposition Record form and retained as part of the agency’s records.

Information for Completing Section A
Question 1 - Recipient’s Full Name: The recipient must personally complete Section A of this form and certify (sign) that the answers are true and
correct. However, if the recipient is unable to read and/or write, the answers (other than the signature) may be written by another person, excluding
the transferor. Two persons (other than the transferor) must then sign as witnesses to the recipient’s answers and signature.
When the recipient is a corporation, company, association, partnership, or other such business entity, an officer authorized to act on behalf of the
business must complete Section A of the form with his or her personal information, sign Section A, and attach a written statement stating: (A) the
firearm is being received for the use of and will be the property of that business entity, and (B) the name and address of that business entity.
If the recipient’s name in Question 1 is illegible, the transferor must print the recipient’s name above the name written by the recipient.
Question 2 - Current Residence Address: If the recipient is a member of the armed forces on active duty acquiring a firearm in the state
where his or her duty station is located, but does not reside at his or her duty station, the recipient must list both his or her duty station address
and his or her residence address in response to Question 2. If you are a U.S. citizen with two states of residence, you should list your current
residence address in response to Question 2 (e.g., if you are receiving a firearm while staying at your weekend home in State X, you should list
your residence address in State X in response to Question 2).
Question 9 - Unique Personal Identification Number (UPIN): For transferees approved to have information maintained about them in the NICS
Voluntary Appeal File, the NICS will provide them with a UPIN, which the recipient should record in Question 9. The transferor may be asked to
provide the UPIN to the NICS or the state.
Question 10(a) - Ethnicity: Hispanic or Latino is defined as a person of Cuban, Mexican, Puerto Rican, South or Central American, or other
Spanish culture or origin, regardless of race.
Question 10(b) – Race: Please select the racial category or categories with which you most closely identify by checking the appropriate box.
Check as many as apply.
Question 11 - State of Residence: The state in which an individual resides. An individual resides in a state if he or she is present in a state with
the intention of making a home in that state. If an individual is a member of the armed forces on active duty, his or her state of residence is the state
in which his or her duty station is located.
If you are a U.S. citizen with two states of residence, you should list your current residence address in response to Question 2 (e.g., if you are
receiving a firearm while staying at your weekend home in State X, you should list your address in State X in response to Question 2).
Question 14 - Alien Admitted to the United States Under a Nonimmigrant Visa: An alien in the United States under a nonimmigrant visa
includes, among others, persons visiting the United States temporarily for business or pleasure, persons admitted to study in the United States who
maintain a residence abroad, and certain temporary foreign workers. The definition does NOT include permanent resident aliens nor does it apply to
nonimmigrant aliens admitted to the United States pursuant to either the Visa Waiver Program or to regulations otherwise exempting them from visa
requirements.
An alien admitted to the United States under a nonimmigrant visa who responds “Yes” to Question 14 must provide a response to Question 15
indicating whether he/she qualifies under an exception.
Question 15 - Exceptions to Nonimmigrant Alien Response: An alien admitted to the United States under a nonimmigrant visa is not prohibited
from purchasing, receiving, or possessing a firearm if the alien: (1) is in possession of a hunting license or permit lawfully issued by the federal
government, a state, or local government, or an Indian tribe federally recognized by the Bureau of Indian Affairs, which is valid and unexpired; (2)
was admitted to the United States for lawful hunting or sporting purposes; (3) has received a waiver from the prohibition from the Attorney General of
the United States; (4) is an official representative of a foreign government who is accredited to the United States Government or the Government’s
mission to an international organization having its headquarters in the United States or who is en route to or from another country to which that alien
is accredited; (5) is an official of a foreign government or a distinguished foreign visitor who has been so designated by the Department of State; or
(6) is a foreign law enforcement officer of a friendly foreign government entering the United States on official law enforcement business.
Persons who qualify under one of these exceptions should answer “Yes” to questions 14 and 15 and provide supporting documentation such as a
copy of the hunting license or letter granting the waiver, which must be recorded in 20(c). If the recipient answered “Yes” to the question, the
transferor must complete 20(c).
The transferor should verify supporting documentation provided by the recipient and must attach a copy of that documentation to this NICS Firearm
Disposition Record form.
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OMB No. 1110-xxxx

Information for Completing Section B

Section B to be completed by the Transferor.
Definition of Transferor. For the purpose of this Firearm Disposition Record form, the term “transferor” refers to the criminal justice or law
enforcement agency and their representatives or employees for the purpose of conducting background checks for the disposition of firearms.
Question 19 - Type of Firearm(s): Check all boxes that apply. “Other” refers to frames, receivers, and other firearms that are not either handguns
or long guns (rifles or shotguns), such as firearms having a pistol grip that expel a shotgun shell, or National Firearms Act (NFA) firearms. If the
weapon is an NFA weapon (machine gun, silencer, etc.), the transferor must contact the Bureau of Alcohol, Tobacco, Firearms and Explosives at
(304) 616-4500.
If a frame or receiver can only be made into a long gun (rifle or shotgun), it is still a frame or receiver not a handgun or long gun. However, they
still are “firearms” by definition, and subject to the same Gun Control Act limitations as any other firearms (18 U.S.C. 921[a][3][b]). Title 18,
U.S.C. 922(b)(1) makes it unlawful to transfer a firearm other than a shotgun or rifle to any person under the age of 21. Since a frame or
receiver for a firearm, to include one that can only be made into a long gun, is a “firearm other than a shotgun or rifle,” it cannot be transferred to
anyone under the age of 21.
Question 20(a) - Identification: List issuing authority (e.g., state, county, or municipality) and type of identification presented (e.g., Virginia driver’s
license) or other valid government-issued identification.
Know the Recipient: Before the transferor may transfer a firearm to a recipient, the transferor must establish the identity, place of residence, and
age of the recipient. The recipient must provide a valid government-issued photo identification to the transferor that contains the recipient’s name,
residence address, and date of birth. The transferor must record the type, identification number, and expiration date (if any) of the identification in
Question 20(a). A driver’s license or an identification card issued by a state in place of a driver’s license is acceptable. Social security cards are not
acceptable. A combination of government-issued documents may be provided. For example, if a U.S. citizen has two states of residence and has
applied for the receipt of a handgun in State X, he may provide a driver’s license (showing his name, date of birth, and photograph) issued by State
Y and another government-issued document (such as a tax document) from State X showing his residence address. If the recipient is a member of
the armed forces on active duty receiving a firearm in the state where his or her duty station is located, but he or she has a driver’s license from
another state, the transferor should list the recipient’s military identification card and official orders showing where his or her duty station is located in
response to Question 20(a).
Question 20(b) - Alternate Documentation: Transferors may accept a combination of valid government-issued documents to satisfy the
identification document requirements of the law. The required valid government-issued photo identification document bearing the name,
photograph, and date of birth of the recipient may be supplemented by another valid government-issued document showing the recipient’s
residence address. This alternate documentation should be recorded in Question 20(b), with issuing authority and type of identification presented.
For example, if a U.S. citizen has two states of residence and is receiving a handgun in State X, he may provide a driver’s license (showing his
name, date of birth, and photograph) issued by State Y and another government-issued document (such as a tax document) from State X showing
his residence address.
Question 20(c) - Documentation for Aliens admitted to the United States under a Nonimmigrant Visa: See information for Question 14. Types
of acceptable documents would include a valid State-issued hunting license or a letter from the United States Attorney General granting a waiver.
An alien in the United States in a nonimmigrant classification. The definition includes, in large part, persons traveling temporarily in the United States
for business or pleasure, persons studying in the United States who maintain a residence abroad, and certain foreign workers. The definition does
NOT include permanent resident aliens. Types of acceptable documents would include a valid state-issued hunting license or a letter from the U.S.
Attorney General granting a waiver.
Question 21 - Background Checks: 28 C.F.R. 25.6(j)(3) allows access to the National Instant Criminal Background Check System (NICS) by
the transferors to conduct a check of the NICS prior to disposing of a firearm to any unlicensed person. The NICS will advise the transferor
whether the system finds any information that the recipient is prohibited by law from possessing or receiving a firearm. For the purpose of this
form, contacts with the NICS include contacts to state agencies designated to conduct NICS checks for the federal government. WARNING:
Any transferor who transfers a firearm to any person they know or have reasonable cause to believe is prohibited from receiving or possessing a
firearm violates the law even if the transferor has complied with the background check requirements of the Brady Handgun Violence Prevention
Act of 1993 (Brady Act). 18 U.S.C. 922[d].
NICS Check: After the recipient has completed Section A of the Firearm Disposition Record form and the transferor has completed Questions 19-20,
and before transferring the firearm, the transferor can contact the NICS. However, the transferor should NOT contact the NICS and should stop the
transaction if: the transferor knows the recipient is prohibited from possessing firearms under federal or state law; the recipient answers “Yes” to
Question 14, unless the recipient has answered “Yes” to Question 14 and also answers “Yes” to Question 15; or the recipient is unable to provide
the documentation required by Questions 20(a), (b), or (c). If a NICS transaction is cancelled by the transferor, the transferor should notify the NICS
Section.
NICS Responses: Firearm should NOT be transferred to any recipient unless the NICS provides a “proceeded” response. If the NICS provides a
“cancelled” or “denied” response, the transferor is prohibited from transferring the firearm to the recipient. Please note state law may impose a
waiting period on transferring firearms.
At the time NICS is contacted, the transferor must record in Questions 21(a) through 21(c): the date of contact, the NICS or state transaction
number, and the initial response provided by the NICS.

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OMB No. 1110-xxxx

Information for Completing Section C
Section C: To be completed by the person who completed Section B (transferor) immediately prior to transferring the firearm(s).
For “denied” and “cancelled” NICS transactions, the person who completed Section B must complete Section C, Questions 28-31. If a NICS
transaction is cancelled by the transferor, the transferor should notify the NICS Section.
Questions 22, 23, 24, 25, and 26 - Firearm Description: These blocks should be completed with the firearm(s) information. Firearms
manufactured after 1968 should all be marked with a serial number. Should you acquire a firearm that is not marked with a serial number, you may
answer question 24 with “NSN” (No Serial Number), “N/A” or “None.”
If more than three firearms are involved in a transaction, the information required by Section C, Questions 22-26, must be provided for the additional
firearms on a separate sheet of paper, which must be attached to the Firearm Disposition Record form covering the transaction.
Additional firearms to be transferred to the recipient may not be added to the Firearm Disposition Record form after the transferor has signed and
dated the form. If there are additional firearms to be disposed of to the recipient after the transferor has signed and dated the Firearm Disposition
Record form, the recipient must complete a new Firearm Disposition Record form and the transferor must conduct a new NICS check.

Federal Prohibitors
Prohibited Persons: Generally, the Brady Act, 18 U.S.C.
interstate commerce of a firearm by any individual who:

922, prohibits the shipment, transportation, receipt, or possession in or affecting

 Has been convicted in any court of a crime punishable by imprisonment for a term exceeding one year (includes state misdemeanors
punishable by imprisonment for a term of two years or more), 18 U.S.C. 922 (g) (1).
EXCEPTION: A person who has been convicted of a felony, or any other crime, for which the judge could have imprisoned the person for
more than one year, or who has been convicted of a misdemeanor crime of domestic violence, is not prohibited from purchasing, receiving, or
possessing a firearm if: (1) under the law of the jurisdiction where the conviction occurred the person has been pardoned, the conviction has
been expunged or set aside, or the person has had civil rights (the right to vote, sit on a jury, and hold public office) restored, AND (2) the
person is not prohibited by the law of the jurisdiction where the conviction occurred from receiving or possessing firearms.
 Is under indictment or information for a crime punishable by imprisonment for a term exceeding one year, 18 U.S.C.
 Is a fugitive from justice, 18 U.S.C.

922 (n).

922 (g) (2).

 Is an unlawful user of or addicted to any controlled substance, 18 U.S.C.

922 (g) (3).

 Has been adjudicated as a mental defective or committed to a mental institution, 18 U.S.C.

922 (g) (4).

Adjudicated as a Mental Defective: (a) A determination by a court, board, commission, or other lawful authority that a person, as a result of
marked subnormal intelligence, or mental illness, incompetency, condition, or disease: (1) Is a danger to himself or to others; or (2) Lacks the
mental capability to contract or manage his own affairs. (b) This term shall include (1) A finding of insanity by a court in a criminal case; and (2)
Those persons found incompetent to stand trial or found not guilty by reason of lack of mental responsibility pursuant to articles 40a and 72b of
the Uniform Code of Military Justice, 10 U.S.C.,
50a, 876b.
Committed to a Mental Institution: A formal involuntary commitment of a person to a mental institution by a court, board, commission, or
other lawful authority. The term includes a commitment for mental defectiveness or mental illness. It also includes commitments for other
reasons, such as for drug use. The term does not include a person in a mental institution for observation or a voluntary admission to a mental
institution.
EXCEPTION - NICS Improvement Amendments Act of 2007 (NIAA): A person who has been adjudicated as a mental defective or
committed to a mental institution is not prohibited if: (1) the person was adjudicated or committed by a department or agency of the federal
government, such as the United States Department of Veteran’s Affairs (“VA”) (as opposed to a state court, state board, or other lawful state
authority); and (2) either: (a) the person’s adjudication or commitment for mental incompetency was set-aside or expunged by the
adjudicating/committing agency; (b) the person has been fully released or discharged from all mandatory treatment, supervision, or monitoring
by the agency; or (c) the person was found by the agency to no longer suffer from the mental health condition that served as the basis of the
initial adjudication. This exception does not apply to any person who was adjudicated to be not guilty by reason of insanity, or based on lack of
mental responsibility, or found incompetent to stand trial, in any criminal case or under the Uniform Code of Military Justice. A person is not
prohibited if the person has received relief from federal firearms disabilities under 18 U.S.C. 922(g)(4) by a proper federal or state authority
under a relief from disabilities program that meets the requirements of the NIAA, Public Law 110-180.
 Is illegally or unlawfully in the United States, 18 U.S.C.

922 (g) (5).

 Has been discharged from the armed forces under dishonorable conditions, 18 U.S.C.

922 (g) (6).

 Having been a citizen of the United States, has renounced U.S. citizenship, 18 U.S.C.

922 (7).

 Is the subject of a court order that restrains the person from harassing, stalking, or threatening an intimate partner or child of such intimate
partner, 18 U.S.C. 922 (g) (8).
Restraining Orders: Firearms may not be sold to or received by persons subject to a court order that: (a) was issued after a hearing which
the person received actual notice and had an opportunity to participate in; (b) restrains such person from harassing, stalking, or threatening an
intimate partner or child of such intimate partner or person, or engaging in other conduct that would place an intimate partner in reasonable
fear or bodily injury to the partner or child; and (c)(i) includes a finding that such person represents a credible threat to the physical safety of
such intimate partner or child; or (ii) by its terms explicitly prohibits the use, attempted use, or threatened use of physical force against such
intimate partner or child that would reasonably be expected to cause bodily injury. An “intimate partner” of a person is either the spouse or
former spouse of the person, the parent of a child of the person, or an individual who cohabits or has cohabited with the person.
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Federal Prohibitors (continued)
 Has been convicted in any court of a misdemeanor crime of domestic violence, 18 U.S.C.

922 (g) (9).

Misdemeanor Crime of Domestic Violence: A federal, state, local, or tribal offense that is a misdemeanor under federal, state, or tribal
law and has, as an element, the use or attempted use of physical force, or the threatened 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. The term includes all misdemeanors that have as an element the use or attempted use of physical force or the
threatened use of a deadly weapon (e.g., assault and battery), if the offense is committed by one of the defined persons.
EXCEPTION: A person who has been convicted of a misdemeanor crime of domestic violence is not prohibited unless: (1) the person was
represented by a lawyer or gave up the right to a lawyer: AND (2) if the person was entitled to a jury, was tried by a jury, or gave up the right
to a jury trial.

Privacy Act Information
Solicitation of this information is voluntary. Disclosure of the recipient’s social security number is voluntary and, if provided, will be used to verify
identity and prevent misidentification. Failure by the recipient to provide information necessary to complete the Firearm Disposition Record form
may result in the inability to initiate a background check.

Paperwork Reduction Act Notice
The information required on this Firearm Disposition Record form complies with the Paperwork Reduction Act of 1995. The purpose of the
information is to determine the eligibility of the recipient to receive firearms under federal law. The information is subject to inspection by
representatives of the CJIS Audit Unit, FBI Criminal Justice Information Services Division.
The estimated average burden associated with this collection is 25 minutes per respondent or record keeper, depending on individual
circumstances. Comments about the accuracy of this burden estimate and suggestions for reducing it should be directed to the FBI Criminal
Justice Information Services Division, NICS Section, Post Office Box 4278, Clarksburg, West Virginia 26302-9922.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid
OMB control number. Confidentiality is not assured.

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