STATE OF NORTH CAROLINA
County
Name And Address Of Applicant Date Of Birth
State
Social Security No.
State Drivers License No. (State Identication No. if no drivers license)
RELEASE OF COURT ORDERS CONCERNING
MENTAL HEALTH AND CAPACITY
FOR PISTOL PURCHASE PERMIT
I hereby authorize and request any and all Clerks of Superior Court of North Carolina to inform the Sheriff of the county named above
whether or not the clerk’s les or records contain any court orders concerning my mental health or capacity. If so, I authorize the clerk
to reveal to the sheriff the court orders within any condential court les or records that the sheriff may reasonably require in order to
determine whether or not to issue a pistol purchase permit to me.
This Release may be treated as a motion in the cause for disclosure pursuant to G.S. 122C-54(d), which disclosure is necessary to
enable the sheriff to determine my qualication to purchase or possess a handgun. I stipulate that a clerk may reveal to the sheriff any
court orders pursuant to any specic or standing order entered in response to or anticipation of this motion.
I understand that further disclosure or redisclosure by the sheriff of any information disclosed to the sheriff pursuant to this Release is
prohibited without my further written consent unless otherwise provided for by state or federal law. I understand that I may revoke this
authorization at any time except to the extent that action has already been taken in reliance on this Release. Even without my express
revocation, this Release will expire upon the satisfaction of the request or one year from the date below, whichever occurs rst.
I authorize the sheriff to photocopy this Release after I sign it, and I authorize any clerk to whom a photocopy of this Release is presented
to rely on the photocopy as being as effective as the original.
NOTE TO CLERK:
This Release authorizes the disclosure of only court orders concerning the mental health or capacity of the applicant for a pistol
purchase permit pursuant to G.S. 14-404. Unless requested via a separate motion under G.S. 122C-54(d) and specically ordered by the court, the clerk
may not release any records or information from an involuntary commitment proceeding other than an actual court order in response to this Release.
Date
Date Signature Of Person Authorized To Administer Oaths
Date Commission Expires
Signature Of Applicant
SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME
SEAL
G.S. 14-404(e1)
AOC-SP-917, New 12/15
© 2015 Administrative Ofce of the Courts
