CONNECTICUT PROBATE COURTS Petition to Restore Right to Purchase, Possess or Transport a Firearm or Ammunition PC-100 REV. 7/18 CONFIDENTIAL Petition to Restore Right to Purchase, Possess or Transport a Firearm or Ammunition PC-100 Page 1 of RECEIVED : Instructions: 1) An adult person having a federal firearms disability under 18 USC sections 922(d) and 922(g)(4) as a result of an adjudication or commitment rendered in Connecticut may use this form to petition for the restoration of the person222s right to purchase, possess or transport a firearm or ammunition. 2)The petitioner must file with this petition the documents listed on Page 2 (items 1 to 5), including acopy of Release of Information re: Petition to Restore Right to Purchase, Possess or Transport a Firearm or Ammunition, PC-150. 3)The petitioner must provide a copy of the petition and all supporting documents to the Departmentof Emergency Services and Public Protection and certify to the court that delivery has been made. 4)The petition and supporting documents must be filed in the probate district where the petitioner resides. 5)For more information, see C.G.S. section 45a-100.6)Type or print the form in ink. Use Second Sheet, PC-180, or an additional sheet if more space is needed. Probate Court Name District Number In the Matter of (Name, address and telephone number) Hereinafter referred to as the petitioner . Date of Birth Social Security Number Persons to whom Notice of Hearing should be given: (Name, address and relationship to petitioner) In addition to the persons listed above, the court will give notice to the Commissioner of Emergency Services and Public Protection, the court that rendered the adjudication or commitment resulting in the federal firearms disability and the court - appointed conservator (s) , if any. The petitioner represents that he or she has a federal firearms disability under 18 USC sections 922(d)(4) and 922(g)(4) as a result of an adjudication or commitment rendered in Connecticut. Due to this disability, the petitioner lost the ability to purchase, possess or transport firearms or ammunition. The petitioner further represents that: By decree of the Probate Court dated , he or she was committed to a hospital for psychiatric disabilities, but is no longer under an order of commitment. By decree of the Probate Court dated , he or she was placed under an order of conservatorship pursuant to C.G.S. section 45a-650 or C.G.S. section 45a- 654. The name and mailing address of the court-appointed conservator(s) is/are: By decree dated, the Probate Court terminated the order for conservatorship. American LegalNet, Inc. www.FormsWorkFlow.com CONNECTICUT PROBATE COURTS Petition to Restore Rights to Purchase, Possess or Transport a Firearm or Ammunition PC - 100 REV. 7/18 CONFIDENTIAL Petition to Restore Right to Purchase, Possess or Transport a Firearm or Ammunition PC-100 Page 2 of The Connecticut Superior Court issued a decree datedresulting in the federal firearms disability. (List the court, the type of matter, the date of the adjudication and the date the order was terminated or expired.) Not including the Probate Court or Superior Court order above, list any court orders that affected the petitioner222s right to purchase, possess or transport a firearm or ammunition. (List the court, type of matter and dates of any order.) The petitioner is not otherwise ineligible or legally barred from purchasing, possessing or transporting firearms or ammuition under the laws of Connecticut or under the equivalent laws of any other state or under federal law. 1. Releases for all of the petitioner222s records related to the petition, including health, mental health, military, immigration, juvenile court, civil court, criminal court records and any other of the petitioner222s records that may relate to the petition. These releases authorize the Commissioner of Emergency Services and Public Protection to obtain any of these records for use at the Probate Court hearing or in any appeal from the Probate Court222s decision. (Attach Release of Information Re Petition to Restore Right to Purchase, Possess or Transport a Firearm or Ammunition, PC-150.) 2. Certified copies of medical records detailing the petitioner's psychiatric history where applicable, includingrecords pertaining to the specific adjudication or commitment that is the subject of this application; 3. Certified copies of medical records from all of the petitioner's current treatment providers, if the petitioner is receivingtreatment; 4.A certified copy of all criminal history information maintained on file by the State Police Bureau of Identification andthe Federal Bureau of Investigation pertaining to the petitioner or a copy of the response from said bureaus indicating that there is no criminal history information on file; and 5. Evidence of the petitioner's reputation, which may include notarized letters of reference from current and pastemployers, family members or personal friends, affidavits from the petitioner or other character evidence. All required information listed above must accompany the petition at the time it is submitted to the court. Information vided after receipt of this petition will not be considered unless submitted in response to a specific request from the court. Any information specifically requested by the court must be certified copies of original documents and must be received by the court no later than 15 days after the date of the request. The court may extend this time period for good cause shown. Failure to provide the requested information within such time period may result in a denial of this petition. WHEREFORE, the petitioner requests that the court approve this petition to restore the petitioner222s right to purchase, possess or transport a firearm or ammunition pursuant to C.G.S. section 45a-100. The representations made in this petition are made under the penalty of false statement. Signature of Petitioner Type or Print Name Date I hereby certify that a copy of this petition, release and all supporting documents submitted to the Probate Court as required by law were delivered to the Commissioner of Emergency Services and Public Protection on the following date: Signature of Petitioner Date American LegalNet, Inc. www.FormsWorkFlow.com