Form ATF F 3210.12 ATF F 3210.12 Certification of Qualifying State Relief from Disabiliti

OMB No. 1140-0094 (xx/xx/xxxx)

U.S. Department of Justice
Bureau of Alcohol, Tobacco, Firearms and Explosives

Certification of Qualifying State Relief
from Disabilities Program

This form is to be used by a State to certify to the U.S. Department of Justice, Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) that it has established a qualifying
mental health relief from firearms disabilities program that satisfies certain minimum criteria (identified below) under the NICS Improvement Admendments Act of 2007, Public
Law 110-180, Section 105, enacted January 8, 2008 (NIAA). This certification is required for States to be eligible for the grants authorized by the NIAA.1 The certifying State
should attach all relevant materials demonstrating compliance with its certification and criteria, which may include statutes, administrative regulations, executive orders, written
policies and/or procedures, program brochures, or other items pertinent to the certification.

Certification
Check
As the authorized State official, I hereby certify that my State has satisfied each of the following minimum criteria to establish
Appropriate Box
a Relief From Disabilities Program under the NIAA:
Not Met
Met
1. State Law: The relief program has been established by State statute, or administrative regulation or order pursuant to State law.
List the legal citation(s) for the relief program:
2. Application: The relief program allows a person who has been formally adjudicated as a mental defective2 or committed
involuntarily to a mental institution3 to apply or petition for relief from Federal firearms prohibitions (disabilities) imposed under
18 U.S.C. §§ 922(d)(4) and (g)(4).

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3. Lawful Authority: A State court, board, commission or other lawful authority (per State law) considers the applicant’s petition
for relief. The lawful authority may only consider applications for relief due to mental health adjudications or commitments that
occurred in the applicant State.
4. Due Process: The petition for relief is considered by the lawful authority in accordance with principles of due process, as
follows:
a. The applicant has the opportunity to submit his or her own evidence to the lawful authority considering the relief application.

c. A record of the matter is created and maintained for review.
5. Proper Record: In determining whether to grant relief, the lawful authority receives evidence concerning and considers the:
a. Circumstances regarding the firearms disabilities imposed by 18 U.S.C. § 922(g)(4);

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6. Proper Findings: In granting relief, the lawful authority issues findings that:
a. The applicant will not be likely to act in a manner dangerous to public safety; and

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7. De Novo Judicial Review of a Denial: The State provides for de novo judicial review of relief application denials that includes
the following principles:
a. If relief is denied, the applicant may petition the State court of appropriate jurisdiction to review the denial, including the
record of the denying court, board, commission or other lawful authority.

8. Required Updates to State and Federal Records: Pursuant to Section 102(c) of the NIAA, the State, on being made aware
that the basis under which the record was made available does not apply, or no longer applies:
a. Updates, corrects, modifies, or removes the record from any database that the Federal or State government maintains and
makes available to the NICS, consistent with the rules pertaining to the database; and

9. Recommended Procedure: It is recommended (not required) that the State have a written procedure (e.g., State law, regulation,
or administrative order) to address the update requirements.
For information regarding the availability of funding for such grants see: http://www.bjs.gov/index.cfm?ty=tp&tid=49#contents
Federal regulations at 27 C.F.R. § 478.11 define the term “adjudicated as a mental defective” as: 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 others; or (2) Lacks the mental
capacity to contract or manage his own affairs. The 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 50a and 72b of the Uniform Code of Military Justice, 10 U.S.C. 850a, 876b.
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Federal regulations at 27 C.F.R § 478.11 define the term “committed to a mental institution” as: A formal commitment of a person to a mental institution by a court, board,
commission, or other lawful authority. The term includes a commitment to a mental institution involuntarily. The term includes 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.
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ATF Form 3210.12
Revised March 2016

Authorized State Official’s Signature

State and Office

Printed Name and Title

Phone

Certification Date

E-mail Address

(For ATF Use Only)
The Relief Program Application Is:

APPROVED
DENIED, for the reasons stated below.

ATF Official’s Signature

ATF Office

Printed Name and Title

Phone

Decision Date

E-mail Address

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Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF)
Firearms and Explosives Industry Division
Mailstop: 6.N.518
99 New York Avenue, NE
Washington, DC 20226
Contact Number: (202) 648-7190

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Please Mail The Form To:

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Reasons for disapproval, or additional comments:

Important Notice
Approval of a relief from disabilities program is valid only if the certifying official above has authority under State law to execute this certification,
and only to the extent there have been no amendments or changes to the State’s relief from disabilities program laws, regulations, directives, or
procedures that were submitted in support of an initial certification. If there have been any changes to applicable State laws or procedures, a new
certification form must be submitted to ATF for approval.
Privacy Act Information: Solicitation of this information is authorized by the NICS Improvement Amendments Act of 2007, Public Law 110-180.
Paperwork Reduction Act Notice
The information required on this form is in accordance with the Paperwork Reduction Act of 1995. The purpose of the information is to determine whether
a State has certified, to the satisfaction of the Attorney General, that it has established a relief from disabilities program in accordance with the requirements
of the NICS Improvement Amendments Act of 2007, Public Law 110-180.
The estimated average burden associated with this collection is 15 minutes per certification, depending on individual circumstances. Comments about the
accuracy of this burden estimate and suggestions for reducing it should be directed to the Reports Management Officer, Document Services Section, Bureau
of Alcohol, Tobacco, Firearms and Explosives, Washington, DC 20226.
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. Confidentially is not assured.
ATF Form 3210.12
Revised March 2016