Certification Letter Template for OMB 1140-0046 2.2012 Final

OMB No. 1140-0046

Certification to be provided to a Federal Firearms Licensee by a Law Enforcement
Officer purchasing a firearm for use in official duties pursuant to 27 CFR § 478.134

[Letterhead of the Law Enforcement Agency]

D
R
(D AF
O T
N C
O O
T PY
U
SE
)

[Date]

[FFL Name]
[FFL address]

Dear [FFL Name]:

This letter certifies that [Purchasing Officer’s Name] is a law enforcement officer with the [Law
Enforcement Agency]. [Purchasing Officer’s Name] will use the firearm(s) purchased from you in official
duties. A record check reveals that [Purchasing Officer’s Name] has no convictions for misdemeanor crimes
of domestic violence.
Sincerely,

(Name of Law Enforcement Agency)

By: _________________________
(Signature of a person in authority within the Law Enforcement Agency, other than the officer purchasing
the firearm)
Paperwork Reduction Act Notice

This request is in accordance with the Paperwork Reduction Act of 1995. The purpose of this information collection is to authorize a law enforcement officer to purchase a firearm once
his/her supervisor has verified through a background check that there is no conviction for a misdemeanor crime of domestic violence. This information is mandatory by statute (Gun Control
Act).
The estimated average burden associated with this collection of information is eight minutes per respondent, 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, 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.