Request for FOID Investigation, Relief and Reinstatement of Firearms Rights Page 2 of 2
By requesting this appeal, I specifically acknowledge that I have waived my rights under the Health Insurance Portability
and Accountability Act (HIPAA), as well as my rights under any state statute governing the confidentiality of medical
records, including but not limited to the Mental Health and Developmental Disabilities Confidentiality Act (740 ILCS
110/5). I certify that any person or entity that may obtain, furnish or exchange such information concerning me shall be
held harmless and not liable for providing this information. I do hereby release from all liability and promise not to sue
said persons or entities, the Illinois State Police, its agents and designees on account of or in connection with any claims,
causes of action, injuries, damages, costs or expenses arising out of the furnishing or exchanging of information.
I affirm that I have legal authority to execute this release in that I am the subject of such records. A photocopy and/or
an electronic copy of this release form will be valid as an original thereof, even though said photocopy and/or electronic
copy does not contain an original writing of my signature.
I understand that:
• I have the right to revoke this consent in writing at any time; regardless, this consent shall terminate upon
expiration of my FOID card; and
• I have the right to inspect and copy any information that is disclosed pursuant to this release.
I have read and fully understand the contents of this “Request for FOID Investigation, Relief and
Reinstatement of Firearms Rights.”
Printed Name: ________________________________________ Date of Birth: ________________________________
Signature: ____________________________________________ Date: ______________________________________
Address, City, State, Zip: ____________________________________________________________________________
Last Four SS#: XXX-XX-________ Other Names Used: _____________________________________________________
Signature of Parent/Guardian of Minor: ________________________________________________________________
Printed Name: _______________________________________ Date: ______________________________________
Please Note: Pursuant to 430 ILCS 65/9.5, within 48 hours of receiving notice of a FOID Card revocation, you must:
(1) surrender your FOID card to the local law enforcement agency where you reside; (2) transfer all firearms in
your possession or control; and (3) complete a Firearms Disposition Record.
Pursuant to 430 ILCS 65/10 (a), you must appeal to the circuit court in your county of residence, not to the ISP, if your
FOID card was denied or revoked for any of the following reasons: forcible felony; stalking; aggravated stalking;
domestic battery; any violation that is a Class 2 or greater felony of the Illinois Controlled Substances Act, the
Methamphetamine Control and Community Protection Act, or the Cannabis Control Act; any felony violation of
Article 24 of the Criminal Code of 1961 or the Criminal Code of 2012; or any adjudication as a delinquent
minor for the commission of an offense that if committed by an adult would be a felony.
This form must be completed, signed, dated, and returned to:
Illinois State Police
Office of Firearms Safety
801 South 7
th
Street, Suite 600-S
Springfield, IL 62703
OR eMail to:
ISP.FOID.Appeals@illinois.gov
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