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Form152A Affidavit Upon Receipt of Firearms (10/2014) Page 1 of 2

STATE OF VERMONT

SUPERIOR COURT FAMILY DIVISION

Unit Docket No.

Plaintiff Name

DOB

Defendant Name

DOB

AFFIDAVIT UPON RECEIPT OF FIREARMS

Subject to the penalties for perjury, I state the following facts to be true to the best of my knowledge and belief.

Please remember to be specific:

1. I have received the following firearms, ammunition and/or weapons belonging to:

____________________________________

Defendant’s Name

(list all of the firearms, ammunition and/or other weapons that you have received with a specific description of

each.)

____________________________________________________________________________________

Form152A Affidavit Upon Receipt of Firearms (10/2014) Page 2 of 2

2. I will be responsible for the secure storage of these firearms, ammunition and/or other weapons and I

will not allow the defendant to obtain possession of them without a court order.

3 I will store all of the above described firearms, ammunition and/or weapons in a secure manner as

follows: (describe specifically the arrangements you have made for the storage of the weapons.)

4. I am not prohibited from owning or possessing firearms by either State or Federal law.

5. I understand the obligations and requirements of the Relief from Abuse Order issued in this case. I

specifically understand that I may personally be subject to civil contempt proceedings if:

a. I violate the terms of the commitments I have made in this affidavit;

b. I permit the Defendant to possess, access or use the firearms, ammunition and/or other weapons

that the Court has ordered me to securely store; or

c. I permit any unauthorized person to possess, access or use the firearms, ammunition and/or other

weapons that the Court has ordered me to securely store.

WARNING

MAKING FALSE STATEMENTS IN THIS AFFIDAVIT IS A CRIME SUBJECT TO A TERM OF IMPRISONMENT OR A

FINE, OR BOTH AS PROVIDED BY 13 V.S.A. §2904.

I hereby swear or affirm that the information above is true to the best of my knowledge and belief.

Signature

Date

Printed Name

Street Address

City/Town/State and Zip Code

Signed and sworn before me:

Date

Signature of Notary Public

Expiration Date

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STATE OF VERMONT SUPERIOR COURT FAMILY DIVISION Unit (Vermont Judiciary)

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