FD-1211 Firearm Related Challenge

Firearm-Related Challenge Request

PRINT ALL INFORMATION IN BLACK

*LAST NAME

FBI

*FIRST NAME

LEAVE BLANK

MIDDLE NAME

FD-1211 (Rev. 05/15/2024)
OMB Control No.1110-0046 (Exp. 05/15/2027)

*SIGNATURE OF PERSON FINGERPRINTED

*DATE OF BIRTH

RESIDENCE OF PERSON FINGERPRINTED

STATE OF RESIDENCE

MM/DD/YYYY

PLACE OF BIRTH

SEX

SOCIAL SECURITY NO.
DATE

RACE

ETHNICITY
HISPANIC OR LATINO

* SIGNATURE OF OFFICIAL TAKING FINGERPRINTS

FINGERPRINTING OFFICIAL'S EMPLOYER AND ADDRESS

NOT HISPANIC OR LATINO

NICS TRANSACTION NUMBER (NTN) AND/OR STATE TRANSACTION NUMBER (STN)

COUNTRY OF CITIZENSHIP

ALIEN OR ADMISSION NUMBER
* ORIGINATING AGENCY IDENTIFIER (ORI)
MISCELLANEOUS NO.

1. R. THUMB

6.L. THUMB

2. R. INDEX

7. L. INDEX

LEFT FOUR FINGERS TAKEN SIMULTANEOUSLY

* DENOTES REQUIRED FIELDS

3. R. MIDDLE

4. R. RING

8. L. MIDDLE

9. L. RING

L. THUMB

R. THUMB

5. R. LITTLE

10. L. LITTLE

RIGHT FOUR FINGERS TAKEN SIMULTANEOUSLY

FEDERAL BUREAU OF INVESTIGATION
UNITED STATES DEPARTMENT OF JUSTICE

CRIMINAL JUSTICE INFORMATION SERVICES DIVISION, CLARKSBURG, WV 26306
___________________________________________________________________________

Firearm-Related Challenge Request
Individuals denied the transfer of a firearm through a Federal Firearm Licensee (FFL) by the FBI or a Point of
Contact state under 18 U.S.C. 922(t), may challenge the denial determination. To assist in determining if you
are not the person associated with the record used in the evaluation of your NICS background check, you
may mail your completed fingerprint card to:

FBI CJIS Division
National Instant Criminal Background Check System (NICS) Section
Post Office Box 4278
Clarksburg, West Virginia 26302-9922

For additional information on the submission of fingerprints to the FBI for challenges of a firearm denial, please visit
https://www.edo.cjis.gov.
Privacy Act Statement:
Authority: The FBI’s acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. The collection of
information on this form is also authorized by 34 U.S.C. 40901(f) and (g) and 28 CFR 25.10.
Principal Purpose: The principal purpose for requesting your fingerprints and associated information is to allow the FBI to respond to your inquiry or challenge of the
reason your firearm, explosive, or related permit transaction was denied by the National Instant Criminal Background Check System (NICS) or Point of Contact (POC)
state. The FBI will search your fingerprints in its Next Generation Identification (NGI) System to confirm your identity and to research the reason for your denial. Providing
your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your inquiry or challenge.
Social Security Account Number (SSAN): Your SSAN (or the last 4 digits) is requested to keep records accurate because other people may have the same name and date of
birth. Your SSAN will be used to assist with verifying your identity. You are not required to provide your SSAN; however, failure to provide your SSAN may delay the
processing of your inquiry or challenge or require the submission of additional information to verify your identity.
Routine Uses: During the processing of your inquiry or challenge and for as long thereafter as your fingerprints and associated information are retained by the FBI, your
information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses
as may be published at any time in the Federal Register, including the Routine Uses for the NICS and the NGI System. Routine uses include, but are not limited to,
disclosures to local, state, tribal, and territorial criminal justice agencies to determine whether transferring a firearm, explosive, or related permit to you is prohibited by state or
federal law, or whether to grant or deny a challenge from a NICS transaction. Information you provide to support your inquiry or challenge may be used to update records in
government databases.

Paper Reduction Act Statement:
According to the Paperwork Reduction Act of 1995, no persons are required to provide the information requested unless a valid OMB control number is displayed. The valid
OMB control number for this information collected is 1110-0046. The time required to complete this information collected is estimated to be 10 minutes, including time
reviewing instructions, gathering, completing, reviewing and submitting the information collection. If you have any comments concerning the accuracy of this time estimate
or suggestions for reducing this burden, please send to: Department of Clearance Officer, United States Department of Justice, Justice Management Division, Policy and
Planning Staff, Washington, DC 20530.
FD-1211

(Rev. 10/31/2023)