Certification of Qualifying State Relief from Disabilities Program

OMB 1140-0094

This form is used by a State to certify to the U.S. Department of Justice, Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) that it has established a qualifying mental health relief from firearms disabilities program, based on certain minimum criteria established by the NICS Improvement Amendment Act of 2007, Public Law 110-180, Section 105, enacted January 8, 2008 (NIAA). This certification is required for States to be eligible for certain grants authorized by the NIAA.

The latest form for Certification of Qualifying State Relief from Disabilities Program expires 2022-08-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form ATF Form 3210.12 Certification of Qualifying State Relief From Disabilities Program Form and Instruction
PL 110-180 (NIAA).pdf Supplementary Document
27 CFR 478.11 Meaning of Terms 4.1.2021.pdf Supplementary Document
Justification for OMB 1140-0094 (ATF F 3210.12) 7.26.2022.docx Supporting Statement A
18 USC 922 Unlawful Acts 12.31.2020.pdf Supplementary Document
Certification of Qualifying State Relief From Disabilities Program Form and Instruction

All Historical Document Collections

202207-1140-003 Approved without change	Extension without change of a currently approved collection	2022-08-05
201905-1140-007 Approved without change	Extension without change of a currently approved collection	2019-05-31
201603-1140-007 Approved without change	Revision of a currently approved collection	2016-03-29
201301-1140-005 Approved without change	Revision of a currently approved collection	2013-01-30
200911-1140-010 Approved without change	Extension without change of a currently approved collection	2009-11-24
200904-1140-004 Approved without change	New collection (Request for a new OMB Control Number)	2009-04-23