CALIFORNIA DEPARTMENT OF JUSTICE BUREAU OF FIREARMS Prohibited Persons Relinquishment Form INSTRUCTIONS Pursuant to Penal Code section 29810, any person who is convicted of any offense listed in sections 29800 or 29805 is prohibited from owning, purchasing, receiving, possessing, or having under his or her custody or control, any firearms, ammunition, and ammunition feeding devices, including but not limited to magazines. Any person subject to section 29800 or 29808, shall relinquish all firearms through a designee within the time periods set forth in subdivision (d) or (e) of Penal Code section 29810, by surrendering the firearms to the control of a local law enforcement agency, selling the firearms to a licensed firearms dealer, or transferring the firearms for storage to a firearms dealer pursuant to Penal Code section 29830. Please note: This form is intended for use in relinquishing firearms only. As a reminder, any person who is convicted of any offense listed in sections 29800 or 29808 is also prohibited from owning or possessing ammunition, ammunition feeding devices, including but not limited to magazines, clips, speed loaders, and autoloaders, The following form allows the defendant to comply with all of the requirements outlined in Penal Code section 29810. To be completed by Defendant Sections A, B, C, D, and E must be completed by the defendant. Section A Complete all personal information. This section is required to establish identity Section B Ifyou do not own, possess, or have under your custody or control, any firearms, ammunition, or ammunition feeding devices, including but not limited to magazines, intial in the box provided in section B, sign, and date where indicated to complete the form. Submit the completed form to your probation officer unless otherwise approved by the court Complete the firearm information (pages 3 and/or 4) and attach the Defendant Supplemental Form (BOF 1023) to report additional firearms as needed. Provide all information about the firearm(s) to be surrendered. Include the current location of the firearm and provide all reasonably available information about the location of the firearms to enable the Power of Attomey (consenting third-party) or Law Enforcement Agency (LEA) Designee to locate the firearms. Provide initials acknowledging the fine and cohabitant advisory. Section applicable, check "Yes" and provide court documentation allowing approval for shortened or enlarged relinquishment Periods, or alternate relinquishment methods. Otherwise, check "No." Section D Complete Power of Attorney (Consenting Third Party)/Law Enforcement Designee Assignment information. Section Complete and sign the declaration section. This section does not need to be signed and dated if you have indicated you do not own, possess or have under your custody or control any firearms, ammunition, or ammunition feeding devices. applicable, have the Power of Attorney (consenting third-party) or LEA Designee complete pages 5 and 6. Once the form has been completed by all parties, the signed form must be submitted to your assigned Probation Officer. The form may be submitted to the probation officer by the defendant or the Power of Attomey Designee.CALIFORNIA DEPARTMENT OF JUSTICE BUREAU OF FIREARMS Prohibited Persons Relinquishment Form CONTINUED INSTRUCTIONS To be completed by Power of Attorney Designee (Consenting Third-Party) Sections F and H are to be completed by the Power of Attomey Designee (consenting third-party) Seaton F Provide personal information to determine your identity. Sign and date the dectaration Section H Provide firearm information, date the firearm was relinquished, and to whom it was relinquished. Attach the Designee ‘Supplemental Form (BOF 1024) to report additional firearms as needed. To be completed by Power of Attorney Designee (Law Enforcement Agency) Sections G and H are to be completed by the LEA Designee. Section G Provide law enforcement agency information, name, and title of law enforcement representative that took possession of the firearm(s), Section H Provide firearm information, date the firearm was relinquished, and to whom it was relinquished. Attach the Designee ‘Supplemental Form (BOF 1024) to report additional firearms as needed.CALIFORNIA DEPARTMENT OF JUSTICE BUREAU OF FIREARMS Prohibited Persons Relinquishment Form (Penal Code 29810) Pursuant to Penal Code section 29810, any person who is convicted of any offense listed in sections 29800 or 29808 is prohibited from owning ‘purchasing, receiving, possessing, or having under his or her custody or control, any firearms, ammunition, and ammunition feeding devices, Including but not limited to magazines. Any person subject to section 29800 or 29805, shall relinquish all firearms through a designee within the time periods set forth in subdivision (4) or (e) of Penal Cade section 29810, by surrendering the firearms to the control ofa local law enforcement agency, selling the firearms to a licensed firearms dealer, or transferring the firearms for storage to a firearms dealer pursuant to section 29830. Please note: This form is intended for use in relinquishing firearms only. As @ reminder, any person who is convicted of any offense listed in ‘sections 29800 or 29805 is also prohibited from owning or possessing ammunition, ammunition feeding devices, including but not limited to ‘magazines, clips, speed loaders, and autoloaders. [A. Prohibited Person Information (Defendant) Last Name Fist Name. Midge Name: Physical Residence Adress: ny State. | Zip Code: Date of Birth (mmidaiyyyy): | Calfomia Driver License or Identification No. [Sex] Phone No. (include area code) |B. Firearm(s) Information (To report additional firearm(s), use supplemental form (BOF 1023)): | do not own, possess, or have under my custody or conto, any firearms, ammmuniton, or ammunition feeding devices, including but not Tita — mites to magazines Sgrewe Date Firearm Type: [Serial Nomber: Make: Mode CHandgun— ORite Shotgun Calter] calor Firearm Orn Barel Lengthy [Cin Category (Le, semi-automatic, single-shot, bolt action: [Com Describe Firearm (dentition Marks): Current Location of Frearm (including address and other information about the firearms specifi location Firearm Type: [Serial Namber: Make: Mode ]OMandgun Rite C Shotgun Calter | Soler ream Origin: Barrel Length: [Ain, [Category (Le. semi-automatic single-shot, bolt action (Cem. Describe Firearm (dentition Marks) Current Location of Firearm (including address and other information about the firearms specifi location Case/DocketCALIFORNIA DEPARTMENT OF JUSTICE BUREAU OF FIREARMS Prohibited Persons Relinquishment Form Fearn Type Seal Nomar ake oder C Handgun ORiNe Shotgun Caliber Color] Frearm Origin Barel Lengthy in, | Category (Le, semi automati, single set, bl asiony Com Describe Firearm (dentition Marks): Current Location of Frearm (including address and other information about the firearm’ speci location Fearn Type Serial Nomar Make Model CHanegun OC RiNe ——_C Shotgun Caliber. [Color | Frearm Ong Barrel Length: |in, | Category Le. semi-automatg, sngle-sht, bol action Com Describe Firearm (Identiicaton Marks) ‘Current Location of Firearm (including address end other information about the frearm's speci location Fallure to fle a completes Prohibited Persons Relinquishment Form (BOF 1022) with the assigned probation officer wihin the specified Tnilal time peri shall constitute an inaction punishable by a fine not exceeding $100. By ining here | understand that any person who lives with me (cohabitant and who owns frearms must store those firearms in Trial _aceardance with Penal Code section 25138. (C. Court Authorized Exception(s): [Yes [] No Pursuant to Penal Code section 29810(, the court has approved a shortened or enlarged relinquishment time period or has allowed for an ‘alteative method for reinquishment (If checked "yes," attach court documentation} |D. Power of Attorney (Consenting Third-Party)/Law Enforcement Designee Assignment: . hereby designate Printed Name of Defendant Printed Namie of Power of AomeyiLEA Designo {to have Power of attomey forthe purpose of transferring or disposing of my frearmis). IE. Defendant Declaration: [As the firearm owner, I nereby declare, under penaly of penury under the laws of the State of Calfomia, thatthe foregoing sue and correct. Tundersiand that las defendant, andlor the designee are obligated to submit a completed Prohiited Persons Relinquishment Form (BOF 1022) o my assigned probation offcer within the specied time period Ly Inave been cleases om aw enforesment custody and understand my designe shal eapose of any frearms | own, possess, oF haven my custody or control within five days of my conviction. 7] Itemain in iw enforcement custogy and unerstand my designee shalsposeof ny fess om, possessor hve in my custody contol within fourteen days of my conviction. “Signature Date Case/DocketCALIFORNIA DEPARTMENT OF JUSTICE BUREAU OF FIREARMS Prohibited Persons Relinquishment Form IF. Power of Attorney Designee (Consenting Third-Party): Last Name Fist Name. Midele Name: Physical Residence Adress: ny: State. | Zip Code: Date oF Birth (midaiyyyy); | Cafomia Driver License or Identification No [Sex | Phone No. (include area code) . hereby agree to accept appointment as Power of Attomey fr the sole purpose of transfering Drinied Name of Power of Atomney Designee or isposingtrearms on behalf the ouner or possessor of the frearmis) Printed Name of Defendant understand that itis my legal responsibility to carry out one ofthe folowing actions on behalf of the defendant surrender the frearms tothe contro ofa local aw lentorcement agency, sel te firearms to Icensed frearms desler, or transfer the frearms to dealer. | understand that |, the designee, shal relinquish the lirearm(s) that are in my possession within five days of when the defendant has been convicted or within fourteen days of when the defendant was convicted, heishe remained in law enforcement custody | understand that | am obligated fo submit this completed BOF 1022 form to the defendants assigned probation loficer within the specie time period in Penal Code Section 29810 (4) and (e). In addition, | shall state the date each frearm was relinquished and the name of the party to whom it was relinquished to and attach corresponding receipts, or the optonal Firearm Disposition Receipt Form (BOF 1025), fom the law lentorcement agency 0” Icensed frearms dealer who took possession of the relinquished frearm(). | deciare under penally of perjury under the laws of the State lot Calfomia, that | am not prohibited by law rom possessing firearms. Som Date |G. Power of Attorney Designee (Law Enforcement Agency): (ORI Number: LEA Name: ‘Street Adcress: iy State: [Zip Code: [Phone Number: [Printed Namie of LEA Representatve/Tive Signature Date Case/DocketCALIFORNIA DEPARTMENT OF JUSTICE BUREAU OF FIREARMS Prohibited Persons Relinquishment Form |H. Firearm Relinquishment Information (To report additional firearms, use supplemental form (BOF 1024) - attach [completed BOF 1025 form(s) andlor receipts) Firearm Type: Serial Number: Make: Mode: (OHendgun Rite Shotgun Calter. [Caer Fream Orin: Barel Length: [(in, [Category (Le. semi-automatic, single-shot, bolt action [Com Describe Firearm (Kentfication Marks) Firearm Relinuished to: Liaw Enforcement Agen: Oo Agency re) ‘ORIN, LEA Name, and Aaaress einguished Firearm Date Mentsee Farm Dear (cro) ‘CFD Wo, Name, and Adress Feinguished Firearm Date Pinied Name and Tie of LEA Representave & CFD Saleeperson/Associate ‘Signature of LER Represenitaive or CFO Salesparsonl Associate Firearm Type: Serial Number: Make: Mode ]CHandgun Rite = C Shotgun Calter. [Color Fream Orin: Barrel Length: [in [Category (Le. semi-automatic, single-shot, bot action [Com Describe Firearm (entiication Marks) Firearm Reinquished to: Law Enforcement Agency Oo Agency ry) ‘ORINO, LEA Name, and Adaress Reinguished Firearm Date Dy Meensee Farm Deaer (cro) CFD Wo, Name, ana Aaaress Reinquished Firearm Date Pied Namie and Tie of LEA Represertave 0: OFD Salesperson/Asscoate ‘Signature of LER Representative or CFD Salesperson Associate Firearm Type: [Serial Number: Make: Mode ]CMandgun Rite = C Shotgun Calter. [Coir Firearm Origin Barel Length: [in [Category (Le, sem-automate, single-shot, bot action: [Con Describe Firearm (dentiicaton Marks) Firearm Relinquished to: Law Enforcoment Agent Oo ‘Agency (eay ‘ORINo, LEA Name, and Adaress einquished Firearm Date teense Firearm Dealer (cro) ‘CFD Wo, Name, and AdtreSs Rainquished Firearm Date ried Namie and Tie oI LEA Represi ve or CFD Salesperson" Associate signature of LER Representative or CFD SafesporsoniAssociate Case/Docket