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NYS Firearms License Request for Public Records Exemption Pursuant to section 400.00 of the NYS Penal Law I am: [ ] an applicant for a firearms license [ ] currently licensed to possess a firearm in NYS Name Date of Firearms License # (if applicable) Date Licensing Authority / County of Issuance or Application I hereby request that any information concerning my firearms license application or firearms license not be a public record. The grounds for which I believe my information should NOT be publicly disclosed are as follows: (check all that are applicable) [ ] 1. My life or safety may be endangered by disclosure because: [ ] A. I am an active or retired police officer, peace officer, probation officer, parole officer, or corrections officer; [ ] B. I am a protected person under a currently valid order of protection; [ ] C I am or was a witness in a criminal proceeding involving a criminal charge; [ ] D. I am participating or previously participated as a juror in a criminal proceeding, or am or was a member of a grand jury; [ ] 2. My life or safety or that of my spouse, domestic partner or household member may be endangered by disclosure for some other reason explained below: (Must be explained in item 5 below) [ ] 3. I am a spouse, domestic partner or household member of a person identified in A, B, C or D of question 1. (Please check any that apply) A [ ] 4. I have reason to believe that I may be subject to unwarranted harassment upon disclosure. 5. (Please provide any additional supportive information as necessary) I understand that false statements made herein are punishable as a class A misdemeanor. I further understand that upon discovery that I knowingly provided any false information, I may be subject to criminal penalties and that this request for an exemption shall become null and void. Signature Date