IN THE _____ JUDICIAL CIRCUIT COURT, ___________________________, MISSOURI Judge or Division: Case Number: Court ORI Number: Plaintiff: vs. Defendant: Co-Defendant: Defendant's Address: Carry Permit/Endorsement Holder Sheriff of Issuance (Date File Stamp) Petition for Revocation of a Concealed Carry Permit or Concealed Carry Endorsement Small Claims Court Plaintiff states to the court that the above-named defendant has a concealed carry permit issued pursuant to sections 571.101 to 571.121, RSMo, or a concealed carry endorsement issued prior to August 28, 2013, and that the defendant's concealed carry permit or concealed carry endorsement should now be revoked because the defendant either never was or no longer is eligible for such a permit or endorsement pursuant to the provisions of sections 571.101 to 571.121, RSMo, specifically plaintiff states that the defendant never was or no longer is eligible for such permit or endorsement for one or more of the following reasons: (Check below each reason that applies to this defendant.) Defendant is not at least nineteen years of age or at least eighteen years of age and a member of the United States Armed Forces or honorably discharged from the United States Armed Forces. Defendant is not a citizen or permanent resident of the United States. Defendant had not resided in this state for at least six months prior to issuance of the permit and does not qualify as a military member or spouse of a military member stationed in Missouri. Defendant has pled guilty to, entered a plea of nolo contendere or has been convicted of a crime punishable by imprisonment for a term exceeding one year under the laws of any state or of the United States or a crime classified as a misdemeanor under the laws of any state and punishable by a term of imprisonment of two years or less that involves an explosive weapon, firearm, firearm silencer, or gas gun. OSCA (10-14) SC105 1 of 2 571.117, 632.005 RSMo American LegalNet, Inc. www.FormsWorkFlow.com Defendant has been convicted of, pled guilty to or entered a plea of nolo contendere to one or more misdemeanor offenses involving crimes of violence within the five-year period immediately preceding application for a concealed carry permit issued pursuant to sections 571.101 to 571.121, RSMo, or a concealed carry endorsement issued prior to August 28, 2013, or the applicant has been convicted of two or more misdemeanor offenses involving driving while under the influence of intoxicating liquor or drugs or the possession or abuse of a controlled substance within the five-year period immediately preceding application for a concealed carry permit issued pursuant to sections 571.101 to 571.121, RSMo or a concealed carry endorsement issued prior to August 28, 2013. Defendant is a fugitive from justice or currently charged in an information or indictment with the commission of a crime punishable by imprisonment for a term exceeding one year under the laws of any state of the United States or a crime classified as a misdemeanor under the laws of any state and punishable by a term of imprisonment of two years or less that involves an explosive weapon, firearm, firearm silencer, or gas gun. Defendant has been discharged under dishonorable conditions from the United States armed forces. Defendant is reasonably believed by the sheriff to be a danger to self or others based on previous, documented behavior pattern. Defendant is adjudged mentally incompetent at the time of application or for five years prior to application, or has been committed to a mental health facility, as defined in section 632.005, RSMo, or a similar institution located in another state, or was released or discharged from a facility in this state pursuant to chapter 632, RSMo, or a similar discharge from a facility in another state, which occurred less than five years ago with a subsequent recommitment. Defendant failed to submit to or failed to clear the State of Missouri and/or national criminal history record checks. Defendant failed to submit an affidavit attesting that the applicant complies with the concealed carry safety training requirement pursuant to section 571.111, RSMo. Defendant is subject to a full order of protection which is still in effect. Defendant is otherwise disqualified from possessing a firearm pursuant to 18 U.S.C. 922(g) or section 571.070, RSMo, because _____________________________________________________________ __________________________________________________________________________________ The plaintiff, subject to penalty of perjury, states that the information contained in this petition is true and correct to the best of the plaintiff's knowledge, is reasonably based upon the plaintiff's personal knowledge and is not primarily intended to harass the defendant named herein. _________________________________________ Date ___________________________________________ Plaintiff OSCA (10-14) SC105 2 of 2 571.117, 632.005 RSMo American LegalNet, Inc. www.FormsWorkFlow.com