Special Tally Sheet for Purchase Permit

ATTACHMENT VIII

Survey Form (sent to local reporting agencies, as applicable)

OMB No. XXXX-XXXX: Approval expires XX/XX/XXXX

PLEASE RETURN BY <Month, Day, Year>

Special Tally Sheet for Firearm Inquiry Statistics (FIST) Program Purchase Permit Statistics

January – December 2010

«ORI» «Company»

	Total
Applications
Rejections
Reasons for Rejection (if known)
Felony Indicted
Felony Conviction
Felony No Disp.
Fugitive
Juvenile
Drug Related
Court Order
Mental Incompetence
Illegal Alien
State Law
Local Ordinance
Domestic Violence
Other*
Arrest and Appeal Information**
Number of Arrests
Reconsiderations† Received
Reconsiderations Reversed
Appeals to Court Filed
Appeals to Court Reversed

*Other includes dishonorable discharge, renunciation of U.S. citizenship, and unspecified reasons.

**Arrest and appeal counts can be sent later, if more time is needed to collect data.

† A reconsideration occurs when the denied person objects to the original decision and asks your agency to

reconsider the denial.

If these statistics cover only part of a month, please enter the last date these statistics cover: ___________________

Please fill in at least the first two rows and fax or mail this form back to us as soon as possible. Even if your agency received zero (0) applications, please send this information. Thank You! For any questions: 1-XXX-XXX-XXXX FAX: (XXX) XXX-XXXX

Completed by: ______________________ MAIL: FIST

<Data Collection Agent>

Telephone: ________________________ <Address>

<City, State, Zip Code>

FAX: _____________________________

E-mail: ______________________________