Fill and Sign the Affidavit of Change of Denomination Form

OMB No. 1140-0024 (04/30/2014) U.S. Department of Justice Bureau of Alcohol, Tobacco, Firearms and Explosives Report of Firearms Transactions 2. Address (number, street, city, state, zip code) 1. Name of Licensee Submitting Report 4. Period Covered 3. Federal Firearms License No. 5. Date 6. Name of Manufacturer and/or Importer Description 7. Model of Firearm Receipt 8. Firearm Serial Number 9. 10. Caliber or Type of Firearm Gauge of (pistol, revolver, Firearm shotgun, rifle,etc.) Under penalties of perjury, I declare that I have examined this report and, to the best of my knowledge and belief, it is true, correct and complete. Sheet (Formerly ATF F4483) 16. Signature 11. Receipt Date 12. From Whom Received (name and address or name and license number) Disposition 13. 14. Disposition Date 15. Name and Address of Person or Firm (see instruction 2) Date of Birth or Federal Firearms License Number of Person or Firm to Whom Delivered 17. Title of ATF Form 5300.5 Revised October 2005 Instructions and Provisions for Preparation and Filing of this Report Instructions 1. Definition: LICENSEE - A person or firm issued a valid and current Federal firearms license to engage in business as a firearms and /or ammunition importer, manufacturer, or dealer, or as a collector of firearms and ammunition curios and relics. Disposition - The sale, trade, loan, rental, giving away, or other transfer made of a firearm. 2. Under Disposition, in item 14 give the complete name of the person or firm to whom sale or other disposition is made, and complete address, including number, street, city, State, and ZIP Code. If order was placed by a person other than the person named or to an address other than shown for the transferee (buyer), give full particulars. If shipment originated elsewhere than at address shown at the top of this report, indicate point of origin. 3. This report is required under authority of 18 U.S.C. 923(g) in the form and manner specified in 27 CFR 478.126(a), and is in addition to all records and reports required under any other provision of law or regulations. 4. All information required by this report must be furnished unless modification is issued, in writing, by the Bureau of Alcohol, Tobacco, Firearms and Explosives Official. 5. Reports must be submitted with respect to all firearms specified in the demand letter requiring the reports to be submitted. 6. Reports must be submitted promptly for the reporting period and to the office specified in the demand letter mentioned above. 7. Failure to submit reports promptly, or the submission of false or incomplete reports, may subject you to criminal liabilities and revocation or denial of your Federal Firearms License. 8. Every Report must be signed by a person authorized to sign and be responsible for the completeness and accuracy of the information furnished. If more than one sheet is used for a report, all sheets should be numbered consecutively and securely fastened together, with the last numbered sheet behind all others. In such case, the signature is required on the last sheet only, but the name of the reporting person or firm must be given in item 1 on each page, with address (item 2) on the first page. The date the report is submitted should be shown in item 5 on each page. 9. In cases where written authority is issued by the Bureau of Alcohol, Tobacco, Firearms and Explosives Official for the submission of copies of commercial record in lieu of reports prepared on this form, each day's reports should be attached to a copy of this form bearing the name and address of the person or firm submitting the report, the date submitted, and the signature of the person authorized to sign reports. Provisions Important: For you Information, Requirements and Penalty Provisions Applicable to Preparation and Submission of this Report Appear Below: Requirement Provisions: Each licensed importer, licensed manufacturer and, licensed dealer, shall maintain such records of importation, production shipment, receipt, sale, or other disposition, of firearms at his place of business, for such period, and in such form as the Attorney General may by regulations prescribe. Such importers, manufacturers and dealers, shall not be required to submit to the Attorney General reports and information with respect to such records and the contents thereof, except as expressly required by this section (18 U.S.C. 923(g)(1)(A)). Each Licensee shall, when required by letter issued by the Attorney General, and until notified to the contrary in writing by the Attorney General, submit on a form specified by the Attorney General, for periods and at the times specified in such letter, all record information required to be kept by this chapter or such lesser record information as the Attorney General in such letter may specify (18 U.S.C. 923 (g)(5)(A)). Each licensee shall, when required by letter issued by the Director of Industry Operations (See memorandum dated February 3, 2000, to Special Agent in Charge National Tracing Center Division regarding delegation of Authority contained in (18 U.S.C. Section 923(g)(5)(A) and 27 C.F.R. Section 478.126) and until notified to the contrary in writing by such officer, submit on Form 4483 (5300.5), Report of Firearms Transactions, for the periods and at the times specified in the letter issued by the Director of Industry Operations, all record information required by this subpart, or such lesser record information as the Director of Industry Operations in his letter may specify. Penalty Provision: Whoever knowingly makes any false statement or representation with respect to the information required by the provisions of this chapter to be kept in the records of a person licensed under this chapter, or in applying for any license or exemption or relief from disability under the provisions of this chapter, shall be fined under this title, imprisoned not more than five years, or both (18 U.S.C. 92f4(a)). Whoever, in any matter within the jurisdiction of the executive, legislative, or judicial branch of the Government of the United States, knowingly and willfully (1) falsifies, conceals or covers up by any trick, scheme, or device a material fact, or (2) makes any materially false, fictitious or fraudulent statements or representations, or (3) makes or uses any false writing or document knowing the same to contain any materially false, fictitious or fraudulent statement or entry, shall be fined under this title, imprisoned not more than 5 years or, if the offense involves international or domestic terrorism (as defined in section 2331), imprisoned not more than 8 years, or both. Paperwork Reduction Act Notice This request in accordance with the Paperwork Reduction Act of 1995. The information collection documents transactions of firearms for law enforcement purposes. ATF uses the information to determine that the transaction is in accordance with law and regulations, and establishes the person(s) involved in the transactions. The information requested is mandatory by statute (18 U.S.C. 923). The estimated average burden associated with this collection of information is 1 hour per respondent or recordkeeper, depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be addressed to Reports Management Officer, Document Services Branch, Bureau of Alcohol, Tobacco, Firearms and Explosives, Washington, D.C. 20226. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. ATF Form 5300.5 Revised October 2005