Fillable STATE OF CONNECTICUT DEPARTMENT OF EMERGENCY SERVICES AND (State of Connecticut/Department of Administrative Services)

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STATE OF CONNECTICUT DEPARTMENT OF EMERGENCY SERVICES AND (State of Connecticut/Department of Administrative Services)

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U.S.A. forms for State of Connecticut/Department of Administrative Services

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STATE OF CONNECTICUT
DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION
DIVISION OF STATE POLICE
DPS-414-C (Rev. 10/02/13) An Affirmative Action/Equal Employment Opportunity Employer
ASSAULT WEAPON CERTIFICATE APPLICATION
(Pursuant to C.G.S. § 53-202a, et. seq., as amended by P.A. 13-3 and P.A.13-220)
Certificate Number:
Instructions:
1. Type or print all information in all sections. (Must be legible or it will be returned.)
2. Submit proof that you purchased this weapon on or prior to April 4, 2013 in the form of a valid sales receipt and/or a DPS-3, or sworn
affidavit that the specified assault weapon was purchased in compliance with state and federal laws.
3. See Appendix A, Declaration of Large Capacity Magazines Form, DESPP-788-C, to declare high capacity magazines.
Note: Thumbprint is required for application to be processed.
Applicant’s Name: (Last, First, Middle)
Permit Number: (If applicable)
Address:(Number, Street, City or Town, State, Zip Code) NO P.O. Boxes
Date of Birth:
Social Security Number (Optional, but will help prevent misidentification):
Home Telephone Number:
Sex: Height: Weight: Motor Vehicle Operator’s License Number and State:
Manufacturer:
Serial Number:
Model:
Caliber:
Unique I.D./Markings:
(notary seal may be placed here)
I understand that any false statement herein, which I do not believe to be true and which is intended to mislead a public servant in the performance of
his or her official function, is punishable by law (See C.G.S. § 53a-157b). I further understand that any statement in this application that is determined to
be false or inaccurate shall constitute grounds for the denial of such application. If approved before the facts are known, such approval shall be void if
based on a false or inaccurate statement. My signature below attests to the accuracy, completeness and truth of all information supplied on this
application:
Applicant Signature: Date:
Signature of Notary Public:
My commission expires:
CERTIFICATE OF POSSESSION OF ASSAULT WEAPON
Certificate Number:
Owner’s name: (Last, First, Middle)
Address: (Number, Street, City or Town, State, Zip Code) NO P.O. Boxes
Date of Birth:
Social Security Number (Optional, but will help prevent misidentification):
Motor Vehicle Operator’s License Number and State:
Manufacturer:
Importer:
Serial Number:
Model:
Caliber:
Unique I.D./Markings:
Signature of Owner
Applicant’s Right Thumbprint
Applicant’s Right Thumbprint
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STATE OF CONNECTICUT DEPARTMENT OF EMERGENCY SERVICES AND (State of ConnecticutDepartment of Administrative Services)

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Completed 13 August 2020

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