Form 1140-0076 (ATF For 1140-0076 (ATF For Application for Restoration of Explosives Privileges

OMB No. 1140-0076

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

Application for Restoration of
Explosives Privileges

1. Name (Last, First, Middle)
4. Aliases

2. Birthplace (City & State or Foreign
Country)

5. Social Security Number (Voluntary)
7a. Telephone Number

6a. Residence Address (No., Street, City, County, State, ZIP Code; cannot be a post office box)

7b. Cell Phone Number
7c. Email Address

6b. Mailing Address
8. Description
Ethnicity
Are you Hispanic or Latino?
Race (Check one or more boxes)

Yes

No

American Indian or Alaska Native

Black or African American

Native Hawaiian or Other Pacific Islander

Asian White
Height

Weight

Hair

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Sex

Eyes

9. Residences During Past Ten Years Beginning With Current Residence In Chronological Order and without breaks ( In columns (b) and (c) enter the months and years of residence.)
Address (Number, Street, City, State, Zip Code, and Country)
(a)

From
(b)

To
(c)

From
(c)

To
(d)

10. Employment Record (List present and prior employers and show month and year of employment.)
Name and Address of Employer (Number, Street, City and State)
(a)

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Position
(b)

11. Convictions (If pardoned for a conviction, write “yes” in column (e) and attach a certified copy of the pardon.)
Specific Crime
(a)

Name and Location of Court
(b)

Sentence Received
(c)

Conviction Date
(d)

Pardoned
(e)

12. Other Arrests
Charge
(a)

13. Probation Officer’s Name, Address and Telephone Number

Date and Place of Arrest
(b)

Disposition
(c)

14. Parole Officer’s Name, Address and Telephone Number

ATF Form 5400.29
Revised ( )

15. Character References (Three references are required. Please include a written statement from each of 3 references, who are not related to the applicant by blood or
marriage and have known the applicant for at least 3 years, recommending the granting of relief.)
Name and Address (Number, Street, City and State)
(a)

Occupation
(b)

Telephone Number
(c)

16. Applicant Data (All questions must be answered by checking “Yes” or “No” box.)
Questions
a. Are you a fugitive from justice?

Yes

Questions

No

b. Are you an unlawful user of or addicted to marijuana or
any depressant, stimulant, or narcotic drug, or any other
controlled substance?
c. Have you ever been convicted in any court of a felony or
any other crime for which the judge could have imprisoned
you for more than one year, even if you received a shorter
sentence, including probation? (If “yes,” see Additional
Information 1.)
d. Are you now on probation or parole, or have not been discharged
from probation or parole for at least two years?

No

i. Have you ever been discharged from the armed forces
under dishonorable conditions? (If “yes,” see Additional
Information 6.)
j. Have you served on active duty in the armed forces? (If
“yes,” check Branch and complete following)
Army

Navy

Marines

Air
Force

Coast
Guard

Service Serial Number

Date Entered Active Duty

Kind of Discharge

Date of Discharge

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e. Are you under indictment or information in any court for a
felony or any other crime for which the judge could
imprison you for more than one year? (An information is a
formal accusation of a crime by a prosecutor.) (If “yes,”
see Additional Information 2.)

Yes

h. Have you ever been the subject of an order by a court or other lawful
authority prohibiting your receipt or possession of firearms?
(If “yes”, see Additional Information 5.)

f. Have you ever been adjudicated mentally defective (which
includes having been adjudicated incompetent to manage
your own affairs) or have you been committed to a mental
institution? (If “yes,” see Additional Information 3.)

g. Have you ever been required by a court or other lawful authority
to undergo mental health evaluation or treatment? (If “yes”, see
Additional Information 4.)

k. Have you ever renounced your United States citizenship?
(If “yes,” see Additional Information 7.)
l. Are you an alien in the United States? (If “yes,” see
Additional Information 8)
US-issued alien number or admission number:

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m. Have you ever applied for a Federal explosives license or
permit? (If “yes,” indicate date application filed.)

17. Complete This Item Only if You Were Ever Issued a Federal Explosives License or Permit.
License or Permit Number

Expiration Date of Latest License or
Permit

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Business Name and Address (License/permit issued under)

The Business is (Check one)

18. I Believe I Should Be Granted Relief Because:

Under penalties imposed by 18 U.S.C. 844, I declare under penalties of perjury, the answers in this application are true, correct, and complete.
19. Signature of Applicant
Mail or Email Application Form To:

20. Date
NCETR - Relief of Disabilities Program
Corporal Road. Bldg. 3750, Redstone Arsenal, Huntsville, AL 35898
Phone Number 256-261-7640
E-Mail: [email protected]

Notes: Two Completed FD 258 (Fingerprint Identification Cards) Must Accompany This Application.

ATF Form 5400.29
Revised (
)

Additional Information
Applications for restoration of explosives privileges must include the following information where applicable. Please note that any record or document of a court or other
government entity or official required to be furnished as indicated below shall be certified by the court or other government entity or official as a true copy.
(1) A “conviction” of a crime punishable by imprisonment for a term exceeding one year is determined under Federal, not State law. A person remains “convicted” of an
offense for purposes of the Federal explosives laws despite issuance of a State pardon, expunction, set aside, or restoration of civil rights. In the case of an applicant
having been convicted of a crime punishable by imprisonment for a term exceeding one year, a certified copy of the indictment or information on which the applicant was
convicted, the judgment of conviction or record of any plea of nolo contendere, or plea of guilty or finding of guilt by the court must be provided.
(2) In the case of an applicant under indictment, a certified copy of the indictment or information must be provided.
(3) In the case of an applicant who has been adjudicated a mental defective or committed to a mental institution, the following must be provided with your application: a certified
copy of the order of a court, board, commission or other lawful authority that made the adjudication or ordered the commitment; any petition that sought to have the applicant
so adjudicated or committed; any medical records reflecting the reasons for commitment and diagnoses of the applicant and any documentation showing that applicant has been
determined by a court, board, commission, or other lawful authority showing the applicant has been restored to mental competency and to be no longer suffering from a mental
disorder and to have all rights restored.
(4) In the case of an applicant who has been required by a court or other lawful authority to undergo a mental health evaluation or treatment, please provide a certified
copy of any order(s) issued by a court, or any other record (such as a police report) which authorized your admission to a mental health facility for evaluation or
treatment.
(5) In the case of an applicant who has been subject to an order by a court or other lawful authority prohibiting your receipt or possession of firearms, please provide a
certified copy of any such order.
(6) In the case of an applicant who has been discharged from the Armed Forces under dishonorale conditions, a certified copy of the applicant’s Certificate of Release
or Discharge from Active Duty (Department of Defense Form 214), Charge Sheet (Department of Defense Form 458), and final court martial order must be provided.

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(7) In the case of an applicant who, having been a citizen of the United States, has renounced his or her citizenship, a certified copy of the formal renunciation of nationality
before a diplomatic or consular officer of the United States in a foreign state, or before an officer designated by the Attorney General when the United States was in a state
of war, must be provided. (See 8 U.S.C. 1481(a)(5) and (6))
(8) In the case of an applicant who is an alien, the following must be provided with your application: documentation that the applicant is an alien who has been lawfully
admitted to the United States; certification from the applicant including the applicant’s US-issued alien number or admission number, country/countries of citizenship,
and immigration status, and certifying that the applicant is legally authorized to work in the United States, or other purposes for which possession of explosives is
required; certification from an appropriate law enforcement agency of the applicant’s country of citizenship stating that the applicant does not have a criminal record;
and, if applicable, certification from a Federal explosives licensee or permittee or other employer stating that the applicant is employed by the employer and must
possess explosive materials for purposes of employment. These certifications must be submitted in English.

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Privacy Act Information

The following information is provided pursuant to Sections 3 and 7(b) of the Privacy Act of 1974:

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1. Authority. Solicitation of this information is made pursuant to 18 U.S.C., Chapter 40. Disclosure of this information by the applicant is mandatory if the applicant wishes
to seek relief from disabilities, i.e., restoration of explosives privileges.
2. Purposes. To determine whether the applicant is eligible to apply for relief from disabilities under 18 U.S.C. 845(b); and to determine whether the restoration of privileges
should be granted.
3. Routine Uses. The information will be used by ATF to make the determinations set forth in paragraph 2. In addition, the information may be disclosed to other Federal,
State, foreign and local law enforcement and regulatory agency personnel to verify information on the application and to aid in the performance of their duties with respect
to the regulation of explosives. (See 68 Federal Register 3551.)
4. Effects of Not Supplying the Information Requested. Failure to supply complete information will delay processing and may cause denial of the application.
5. Disclosure of Social Security Number. Disclosure of the individual’s social security number is voluntary. Solicitation of this information is made pursuant to 18 U.S.C.
845(b), and E.O. 9397, Nov. 22, 1943, and may be used to verify the identity of the applicant.
Paperwork Reduction Act Notice
This request is in accordance with the Paperwork Reduction Act of 1995. The information is required in order to determine whether or not explosives privileges may be
restored. It is used to conduct an investigation to establish if it is likely that the applicant will act in a manner dangerous to public safety or contrary to public interest. The
information is required in order to restore privileges under 18 U.S.C. 845(b).
The estimated average burden associated with this collection of information is 30 minutes per respondent or recordkeeper, depending on individual circumstances. Comments
concerning the accuracy of this burden estimate and suggestions for reducing this burden should be addressed to Reports Management Officer, Document Services Branch,
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 a currently valid OMB control number.

ATF Form 5400.29
Revised (
)

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

Authority for Release of Information

This Sheet Must Accompany All Copies of ATF Form 5400.29, Application for Restoration of Explosives Privileges
1. Authority. The authority to solicit information is stated in ATF Form 5400.29, Application for Restoration of Explosives Privileges. This form is in
compliance with the Privacy Act of 1974.
2. Purpose and Use. The information you supply by signing this release of information form will be used principally to aid in the completion of a background investigation conducted by the Department of Justice, Bureau of Alcohol, Tobacco, Firearms, and Explosives (ATF), pursuant to 18 U.S.C.
845(b), in conjunction with your Application for Restoration of Explosives Privileges.
3. Effects of Nondisclosure. Your signature on this Authority for Release of Information form is voluntary; however, your failure to complete this form may
mean that the required information cannot be obtained to complete your investigation, and may result in the denial of your application.
Name of Applicant (Include Last, First, and Middle Name and all aliases used)

Date of Birth

Present Address (Number, Street, City, State, Zip Code, Country)

Telephone Number (Include Area
Code)

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This release, when presented by a duly authorized representative of the Department of Justice, will constitute my consent and authority to examine and obtain copies and
abstracts of records and to receive statements and information regarding my background. Specifically, I hereby authorize the release of the following data or records to the
Department of Justice (ATF):
Employment Information, Military Information, Records, Police and Criminal Records, Medical History

Medical Information Records
If you answered “yes” to items 16(b) or (f) on ATF Form 5400.29, complete the following section.
Name of Attending Physicians, Alcohol or Drug Abuse
Rehabilitation Centers, or Mental Health Institutions

Area Code and
Telephone Number

Signature of Applicant

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Address
(Including City, State and Zip Code)

Date

Special Agent (Signature)

Date

ATF Form 5400.29
Revised November 2015