Fill and Sign the Court of Washington County of No Firearm Courtswagov Form

Notice of I neligibility to Possess Firearm (NTIPF) Page 1 of 2 MP 001 ( 07 /2019 ) RCW 9.41.047 , RCW 10.77.088, MPR 3.5 Court of Washington County of ___________________________________ Plaintiff/ Petitioner vs. ___________________________________ Defendant/Respondent DOB:____________ No. Notice of Ineligibility to Possess a Firearm (NTIPF) Clerk’s Actio n Required (DOL and NICS) To the Defendant/Respondent : You are advised that : [ ] the court committed you for mental health treatment under chapter 71.05 RCW, chapter 71.34 RCW, or chapter 10.77 RCW. [ ] the court dismissed the criminal charges against you under RCW 10.77.088 , and the court has found that you have a history of one or more violent acts. You are required to immediately surrender any concealed pistol license s. You may not possess a firearm until your right to do so has been restored by a co urt of record. This notice has been read to the Defendant/ Respondent. Dated: Defendant/Respondent’s Signature Judge/Commissioner/Pro Tem The information below has been filled in by the State based on available information. The date of commitment: ___ _____________________________________. The date of dismissal under RCW 10.77.088: _______________________________________. [ ] A copy of the Defendant/Respondent’s driver’s license or identicard is attached, or Defendant/Respondent’s Last Name , First Name Middle Name List any Aliases: Notice of I neligibility to Possess Firearm (NTIPF) Page 2 of 2 MP 001 ( 07 /2019 ) RCW 9.41.047 , RCW 10.77.088, MPR 3.5 Residential Address (Street) (City) (State) (Zip) Date of Birth (month/date/year) Driver’s License/ID Number Race: Sex: Weight: Height: Eyes: Hair: Court NCIC No. The Court Clerk Submit s to : Dept. of Licensing, Business & Professions Firearms Unit, firearms@dol.wa.gov (PO Box 9649, Olympia, WA 98507 -9649), and to the National Instant Criminal Background Check System (NICS).