The information obtained from this inquiry will be used to determine
whether under the new legislation, 18 U.S.C. § 922(g)(9), you are barred
from possessing a firearm. Reassignment or other administrative action
may be necessary on the information provided in this questionnaire.

YOU MUST COMPLETE THIS QUALIFICATION INQUIRY AND PROVIDE IT TO YOUR
IMMEDIATE SUPERVISOR WITHIN TEN (10) WORKING DAYS OF RECEIPT. REFUSAL OR
FAILURE TO RESPOND, OR SUBMITTING RESPONSES THAT ARE INCOMPLETE OR
UNTRUE, MAY BE GROUNDS FOR DISCIPLINARY ACTION, UP TO AND INCLUDING
REMOVAL.

Neither your answers, nor any information or evidence obtained by reason
of your answers, can be used against you in any criminal prosecution for
violation of 18 U.S.C. § 922(g)(9). However, the answers you furnish and
any information or evidence resulting therein may be used against you in
a prosecution for knowingly and willfully providing false statements or
information, and may be a basis for agency disciplinary action.

18 U.S.C. § 922(g)(9) makes it a felony for anyone who has been
convicted under federal or state law of a misdemeanor crime of domestic
violence to possess any firearm or ammunition. A "misdemeanor crime of
domestic violence" is defined generally as any offensewhether or not
explicitly described in a statute as a crime of domestic violencewhich
has as its factual basis the use or attempted use of physical force, or
the threatened use of a deadly weapon, committed by the victim\'s
current or former domestic partner, parent, or guardian. The law further
provides that:

(B)(I) A person shall not be considered to have been convicted of such
an offense for purposes of this chapter unless:

(I) The person was represented by counsel in the case, or knowingly and
    intelligently waived the right to counsel in the case; and

(II) In the case of a prosecution for an offense described in the
     paragraph for which a person was entitled to a jury trial in the
     jurisdiction in which the case was tried, either

\(a\) The case was tried by a jury, or

> \(b\) The person knowingly or intelligently waived the right to have
> the case tried by a jury, by guilty plea, or otherwise.
>
> \(c\) A person shall not be considered to have been convicted of such
> an offense for purposes of this chapter if the conviction has been
> expunged or set aside, or is an offense for which the person has been
> pardoned or has had civil rights restored, unless the pardon,
> expungement, or restoration of civil rights expressly provides that
> the person may not ship, transport, possess, or receive firearms.

Certification. To resolve any question whether you are affected by the
statute, that is, whether you have been convicted of a misdemeanor crime
of domestic violence within the meaning of the statute, you should
contact your immediate supervisor, your agency ethics officer, a union
representative, or a private attorney.^1^

1.) Have you even been convicted of a misdemeanor crime of domestic
violence within the meaning of the statute?

Initial and date: Yes.\_\_\_\_\_\_\_ No.\_\_\_\_\_\_\_ I am not
certain.\_\_\_\_\_\_\_

2.) If you answered "yes" to the first question, please provide the
following information with respect to the conviction:

Court/Jurisdiction:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Docket/Case Number:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Statute/Charge:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date Sentenced:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3.) If you answered "yes" to the first question, was that conviction
expunged or set aside or have you been pardoned for the offense or
otherwise had your civil rights restored without a continuing
prohibition of the use or possession of firearms or ammunition?

Initial and date: Yes. \_\_\_\_\_\_\_\_ No. \_\_\_\_\_\_\_\_

If you answer "yes" to this question, please provide documentation of
the expungement, set aside, or pardon.

IF YOU ANSWERED \"YES\" OR \"I AM NOT CERTAIN\" TO THE FIRST QUESTION,
UNTIL YOU PROVIDE DOCUMENTATION OF ANY EXPUNGEMENT, SET ASIDE, OR
PARDON, YOU MUST IMMEDIATELY TURN OVER ANY GOVERNMENT-ISSUED FIREARMS OR
AMMUNTION TO YOUR SUPERVISOR. ADDITIONALLY, YOUR AUTHORIZATION TO CARRY
A GOVERNMENT-OWNED OR PERSONALLY-OWNED FIREARM AND AMMUNITION IS
RESCINDED.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

^1^A conviction "within the meaning of the statute" means those
convictions that have not been expunged or set aside, or for which the
individual had not received a pardon.

I hereby certify that, to the best of my information and belief, all of
the information provided by me is true, correct, and complete. I
understand that false or fraudulent information provided herein may be
grounds for adverse personnel actions, up to and including removal, and
also is criminally punishable pursuant to Federal law, including 18
U.S.C. § 1001.

Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_