Form152A Affidavit Upon Receipt of Firearms (10/2014) Page 1 of 2 STATE OF VERMONT SUPERIOR COURT FAMILY DIVISION Unit Docket No. Plaintiff Name DOB Defendant Name DOB v . AFFIDAVIT UPON RECEIPT OF FIREARMS Subject to the penalties for perjury, I state the following facts to be true to the best of my knowledge and belief. Please remember to be specific: 1. I have received the following firearms, ammunition and/or weapons belonging to: (list all of the firearms, ammunition and/or other weapons that you have received with a specific description of each.) American LegalNet, Inc. www.FormsWorkFlow.com Form152A Affidavit Upon Receipt of Firearms (10/2014) Page 2 of 2 2. I will be responsible for the secure storage of these firearms, ammunition and/or other weapons and I will not allow the defendant to obtain possession of them without a court order. 3 I will store all of the above described firearms, ammunition and/or weapons in a secure manner as follows: (describe specifically the arrangements you have made for the storage of the weapons.) 4. I am not prohibited from owning or possessing firearms by either State or Federal law. 5. I understand the obligations and requirements of the Relief from Abuse Order issued in this case. I specifically understand that I may personally be subject to civil contempt proceedings if: a. I violate the terms of the commitments I have made in this affidavit; b. I permit the Defendant to possess, access or use the firearms, ammunition and/or other weapons that the Court has ordered me to securely store; or c. I permit any unauthorized person to possess, access or use the firearms, ammunition and/or other weapons that the Court has ordered me to securely store. WARNING MAKING FALSE STATEMENTS IN THIS AFFIDAVIT IS A CRIME SUBJECT TO A TERM OF IMPRISONMENT OR A FINE, OR BOTH AS PROVIDED BY 13 V.S.A. 2472904. I hereby swear or affirm that the information above is true to the best of my knowledge and belief. Signature Date Printed Name Street Address City/Town/State and Zip Code Signed and sworn before me: Date Signature of Notary Public Expiration Date American LegalNet, Inc. www.FormsWorkFlow.com