INQUIRY REGARDING CONVICTIONS FOR
MISDEMEANOR CRIMES OF DOMESTIC VIOLENCE
Pursuant to Title 18 U.S.C. Section 922 (g) (9)
The purpose of this form is to obtain information that will assist the New York City Police Department in determining
whether any of its candidates have been adversely affected by federal law, title 18 U.S.C. Section 922 (g) (9). You are directed
to complete this form and return it, within ten (10) working days of your receipt of the form, to your Character Assessment
Section Investigator. Failure to complete this form truthfully and within ten (10) days of receipt may result in your not being
hired.
Candidates may seek the advice of counsel prior to responding to the questions contained in this form. However,
the form must be completed, notarized, and submitted to your investigator within ten (10) days of receipt. The New York City
Police Department will notify the Licensing agency and/or appropriate authorities when informed of a candidate who reports
the possession of fi rearms or ammunition in violation of this law.
1. Have you ever been convicted of a Misdemeanor Crime of Domestic Violence, in any court, anywhere,
including a military tribunal? Indicate: YES NO
A "Misdemeanor Crime of Domestic Violence" is defi ned by 18 U.S.C. 921 (a) (33) (A) as follows: An offense that
(i) is a misdemeanor under federal or state law and (ii) has as an element, the use or attempted use of physical force or the
threatened use of a deadly weapon, committed by:
a.- A current or former spouse, parent or guardian of the victim.
b.- A person with whom the victim shares a child in common.
c.- A person who is cohabiting with or has cohabited with the victim as a spouse,
parent or guardian.
d.- A person similarly situated to a spouse, parent or guardian of the victim.
2. If you answered "yes" to question No.1, provide the following information with respect to the conviction:
Court/Jurisdiction
Docket/Case#
Statute/Charge
Date Sentenced
If you answered "yes" to question No.1:
a. Were you pardoned? Indicate: YES NO
b. Was your conviction expunged? Indicate: YES NO
c. If any of your civil rights were removed as a result of your conviction, have all of your rights been
restored? Indicate: N/A YES NO
3. If you answered "Yes" to question 2a, b or c attach copies of documents verifying your response.
I hereby attest that all of the statements herein are true under the penalty of perjury and its related
offenses pursuant to section 210 of the Penal Law.
Name ____________________________________________________ Exam No. _______________________
List No. ___________ Position Sought _______________________________ S.S. No. ____________________
Date ________________________ Signature _____________________________________________________
Sworn to before me this ____________________ day of ______________________________ , 20 _________
_______________________________________
Notary Public
DOMESTIC VIOLENCE INQUIRY – CANDIDATE
PD 407-090 (Rev. 09-19)
CAS-15
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