U.S. Department of Justice
Bureau of Alcohol, Tobacco, Firearms and Explosives
Certication of Qualifying State Relief
from Disabilities Program
OMB No. 1140-0094 (08/31/2022)
This form is to be 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 rearms disabilities program that satises certain minimum criteria (identied below) under the NICS Improvement Admendments Act of 2007, Public
Law 110-180, Section 105, enacted January 8, 2008 (NIAA). This certication is required for States to be eligible for the grants authorized by the NIAA.
The certifying State
should attach all relevant materials demonstrating compliance with its certication and criteria, which may include statutes, administrative regulations, executive orders, written
policies and/or procedures, program brochures, or other items pertinent to the certication.
As the authorized State ocial, I hereby certify that my State has satised each of the following minimum criteria to establish
a Relief From Disabilities Program under the NIAA:
Appropriate Box
Not Met
1. State Law: The relief program has been established by State statute, or administrative regulation or order pursuant to State law.
2. Application: The relief program allows a person who has been formally adjudicated as a mental defective
or committed
involuntarily to a mental institution
to apply or petition for relief from Federal rearms prohibitions (disabilities) imposed under
18 U.S.C. §§ 922(d)(4) and (g)(4).
3. Lawful Authority: A State court, board, commission or other lawful authority (per State law) considers the applicant’s petition
for relief. The lawful authority may only consider applications for relief due to mental health adjudications or commitments that
occurred in the applicant State.
4. Due Process: The petition for relief is considered by the lawful authority in accordance with principles of due process, as
a. The applicant has the opportunity to submit his or her own evidence to the lawful authority considering the relief application.
b. An independent decision maker someone other than the individual who gathered the evidence for the lawful authority
acting on the application reviews the evidence.
c. A record of the matter is created and maintained for review.
5. Proper Record: In determining whether to grant relief, the lawful authority receives evidence concerning and considers the:
a. Circumstances regarding the rearms disabilities imposed by 18 U.S.C. § 922(g)(4);
b. Applicant’s record, which must include, at a minimum, the applicant’s mental health and criminal history records; and
c. Applicant’s reputation, developed, at a minimum, through character witness statements, testimony, or other character
6. Proper Findings: In granting relief, the lawful authority issues ndings that:
a. The applicant will not be likely to act in a manner dangerous to public safety; and
b. Granting the relief will not be contrary to the public interest.
7. De Novo Judicial Review of a Denial: The State provides for de novo judicial review of relief application denials that includes
the following principles:
a. If relief is denied, the applicant may petition the State court of appropriate jurisdiction to review the denial, including the
record of the denying court, board, commission or other lawful authority.
b. In cases of denial by a lawful authority other than a State court, the reviewing court has discretion to receive additional
evidence necessary to conduct an adequate review.
c. Judicial review is de novo in that the reviewing court may, but is not required to, give deference to the decision of the lawful
authority that denied the application for relief.
8. Required Updates to State and Federal Records: Pursuant to Section 102(c) of the NIAA, the State, on being made aware
that the basis under which the record was made available does not apply, or no longer applies:
a. Updates, corrects, modies, or removes the record from any database that the Federal or State government maintains and
makes available to the NICS, consistent with the rules pertaining to the database; and
b. Noties the Attorney General that such basis no longer applies so that the record system in which the record is maintained is
kept up to date.
For information regarding the availability of funding for such grants see: http://www.bjs.gov/index.cfm?ty=tp&tid=49#contents
Federal regulations at 27 C.F.R. § 478.11 dene the term “adjudicated as a mental defective” as: A determination by a court, board, commission, or other lawful authority
that a person, as a result of marked subnormal intelligence, or mental illness, incompetency, condition, or disease: (1) Is a danger to himself or others; or (2) Lacks the mental
capacity to contract or manage his own aairs. The term shall include (1) A nding of insanity by a court in a criminal case; and (2) Those persons found incompetent to stand
trial or found not guilty by reason of lack of mental responsibility pursuant to articles 50a and 72b of the Uniform Code of Military Justice, 10 U.S.C. 850a, 876b.
Federal regulations at 27 C.F.R § 478.11 dene the term “committed to a mental institution” as: A formal commitment of a person to a mental institution by a court, board,
commission, or other lawful authority. The term includes a commitment to a mental institution involuntarily. The term includes commitment for mental defectiveness or
mental illness. It also includes commitments for other reasons, such as for drug use. The term does not include a person in a mental institution for observation or a voluntary
admission to a mental institution.
9. Recommended Procedure: It is recommended (not required) that the State have a written procedure (e.g., State law, regulation,
or administrative order) to address the update requirements.
ATF Form 3210.12
Revised March 2016
List the legal citation(s) for the relief program:
Authorized State Ocial’s Signature
State and Oce Certication Date
Printed Name and Title Phone E-mail Address
(For ATF Use Only)
The Relief Program Application Is:
DENIED, for the reasons stated below.
ATF Ocial’s Signature
ATF Oce Decision Date
Printed Name and Title Phone E-mail Address
Reasons for disapproval, or additional comments:
Please Mail The Form To:
Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF)
Firearms and Explosives Industry Division
Mailstop: 6.N.518
99 New York Avenue, NE
Washington, DC 20226
Contact Number: (202) 648-7190
Important Notice
Approval of a relief from disabilities program is valid only if the certifying ocial above has authority under State law to execute this certication,
and only to the extent there have been no amendments or changes to the State’s relief from disabilities program laws, regulations, directives, or
procedures that were submitted in support of an initial certication. If there have been any changes to applicable State laws or procedures, a new
certication form must be submitted to ATF for approval.
Privacy Act Information: Solicitation of this information is authorized by the NICS Improvement Amendments Act of 2007, Public Law 110-180.
Paperwork Reduction Act Notice
The information required on this form is in accordance with the Paperwork Reduction Act of 1995. The purpose of the information is to determine whether
a State has certied, to the satisfaction of the Attorney General, that it has established a relief from disabilities program in accordance with the requirements
of the NICS Improvement Amendments Act of 2007, Public Law 110-180.
The estimated average burden associated with this collection is 15 minutes per certication, depending on individual circumstances. Comments about the
accuracy of this burden estimate and suggestions for reducing it should be directed to the Reports Management Ocer, Document Services Section, 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. Condentially is not assured.
ATF Form 3210.12
Revised March 2016
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