Certification of Qualifying State Relief from Disabilities Program (ATF Form 3210.12)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 3210.12 Certification of Qualifying State Relief from Disabilities Program	Form and Instruction	Modified	Available
Form 3210.12 Certification of Qualifying State Relief From Disabilities Program	Form and Instruction	Modified	Available
PL 110-180 (NIAA).pdf	Supplementary Document	Uploaded 2022-08-05	Repair queued
PL 110-180 (NIAA).pdf	Supplementary Document	Uploaded 2022-08-05	Available
27 CFR 478.11 Meaning of Terms 4.1.2021.pdf	Supplementary Document	Uploaded 2022-08-05	Repair queued
27 CFR 478.11 Meaning of Terms 4.1.2021.pdf	Supplementary Document	Uploaded 2022-08-05	Available
1140-0094 supporting statement part A 2025.w mon.docx	Supporting Statement A	Uploaded 2025-11-03	Repair queued
1140-0094 supporting statement part A 2025.w mon.docx	Supporting Statement A	Uploaded 2025-11-03	Available
18 USC 922 Unlawful Acts 12.31.2020.pdf	Supplementary Document	Uploaded 2022-08-05	Repair queued
18 USC 922 Unlawful Acts 12.31.2020.pdf	Supplementary Document	Uploaded 2022-08-05	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
188936	Certification of Qualifying State Relief From Disabilities Program	Form and Instruction	Modified	Certification of Qualifying State Relief from Disabilities Program
188936	Certification of Qualifying State Relief From Disabilities Program	Form and Instruction	Modified

ICR Details

OMB Control No: 1140-0094	ICR Reference No: 202510-1140-005
Status: Active	Previous ICR Reference No: 202207-1140-003
Agency/Subagency: DOJ/ATF	Agency Tracking No:
Title: Certification of Qualifying State Relief from Disabilities Program (ATF Form 3210.12)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/11/2026
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/30/2025
Terms of Clearance: In accordance with 5 CFR 1320, this information collection is approved

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2029	36 Months From Approved	05/31/2026
Responses	10	0	50
Time Burden (Hours)	3	0	13
Cost Burden (Dollars)	0	0	29

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Abstract: NICS Improvement Act sought to address gap in information from states about mental health adjudications/commitments prohibiting purchase of firearms. It authorizes grants for states to improve quality and completeness of records available to NICS, but to qualify for a grant, a state official must certify to ATF that the state has implemented a qualifying program permitting persons adjudicated as a mental defective, or committed to an institution to apply for relief from that firearms disability.

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Authorizing Statute(s): US Code: 18 USC 922 Name of Law: Unlawful Acts
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 37567	08/05/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 51410	11/17/2025
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Certification of Qualifying State Relief From Disabilities Program	3210.12	Certification of Qualifying State Relief from Disabilities Program

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	10	50	0	0	-40	0
Annual Time Burden (Hours)	3	13	0	0	-10	0
Annual Cost Burden (Dollars)	0	29	0	-6	-23	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/30/2025

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