Certification For Firearm Possession
Developmentally Disabled
Pursuant to: 430 ILCS 65/10(c-10)
Instructions: This certification form must be completed by an Illinois licensed physician, clinical psychologist or qualified examiner as
defined in 405 ILCS 5/1-122 (hereinafter referred to as “Evaluator”) and returned directly to the:
Illinois State Police
Office of Firearms Safety
801 South Seventh Street, Suite 600-S
Springfield, Illinois 62703-2487
1. The Evaluator completing this form must have:
• First, reviewed all collateral mental health information supplied by the applicant and others, and
• Then, performed a mental health evaluation of the petitioner prior to completing the form.
2. Do not give the original form to the petitioner; please, mail it directly to the Illinois State Police.
NAME OF FOID CARD PETITIONER: DATE OF BIRTH: / /
Last, First, Middle Initial
Certification of Evaluator
By my signature below, I affirm:
• I am a physician, clinical psychologist or qualified examiner as defined in 405 ILCS 5/1-122;
• The petitioner has been under my care since (date);
• I have administered (or overseen the administration of) an evaluation of the petitioner. I have personally assessed this petitioner
for the diagnosis of developmentally or intellectually disabled.
• I have personally assessed this petitioner for risk of suicidal or homicidal ideation and/or any threat of violence to their intimate
partner, family, self, and others; and,
• I have determined with a reasonable degree of medical certainty the determinations listed below:
1. The petitioner has been diagnosed as developmentally disabled as defined in 405 ILCS 5/6 -103.2.
2. The petitioner’s diagnosis as developmentally disabled is considered “mild”?
3. Please mark any area of major life activity in which there are significant limitations exhibited by
the petitioner.
Receptive and
Expressive Language
Learning
4. Does the petitioner exhibit limitations in following/understanding rules or obeying laws?
5. The petitioner exhibits behaviors that could be construed as a serious threat of physical violence against
a reasonably identifiable victim.
6. The petitioner poses a clear and imminent risk of serious physical injury to themselves or another
person.
7. The petitioner demonstrates threatening physical or verbal behavior, such as violent, suicidal, or assaultive
threats, actions, or other behavior.
8.Please feel free to further explain or qualify any of your responses:
Name of evaluator (please print):
ISP 2-669 (11/20)
