Print Form Clear Form Report of Conviction to the ISP for Misdemeanor Crimes of Domestic Violence Federal Firearms Disqualification (11/08/13) CCCR N008 REPORT OF CONVICTION TO THE ILLINOIS STATE POLICE FOR MISDEMEANOR CRIMES OF DOMESTIC VIOLENCE FEDERAL FIREARMS DISQUALIFICATION 725 ILCS 5/112a-11.2, 18 U.S.C. § 922(g)(9), Pub. L. 110-180 The information below is being collected and reported to state and federal firearms regulatory authorities in support of Illinois Compiled Statutes 725 ILCS 5/112a-11.2, 18 U.S.C. § 922(g)(9), and Pub. L. 110-180, if applicable. Defendant's Last Name Defendant's First Name Defendant's Middle Name Defendant's Date of Birth Gender County Court Location Case Number FOID # (if applicable By a judgment of the court, the offender was convicted of the misdemeanor crime(s) below, in a proceeding in which the offender was represented by counsel, or knowingly and intelligently waived the right to counsel, through a jury trial, or if the offender knowingly and intelligently waived the right to a jury trial, through a non-jury trial, or a plea of guilty or nolo contendere. A. OFFENDER'S CURRENT OR FORMER RELATIONSHIP TO THE VICTIM: Spouse of the victim Child in common with the victim. Cohabitation with the victim as a spouse or a person similarly situated to a spouse, or intimate cohabitation with the victim. Parent, stepparent, or guardian of the victim. Cohabitation with the victim as a parent or guardian, or a person similarly situation to a parent or guardian. Unidentified (specify): B. CONVICTED OFFENSE (CHECK ALL THAT APPLY): 720 ILCS 5/12-1 Assault 720 ILCS 5/8-4 720 ILCS 5/12-2 Aggravated Assault 720 ILCS 5/12-3.2 720 ILCS 5/12-3 Battery 720 ILCS 5/12-3.4 720 ILCS 5/12-5 Reckless Conduct 720 ILCS 5/12-3.5 Attempt (Domestic Battery) Domestic Battery Violation of an Order of Protection Interfering with the Reporting of Domestic Violence C. DID THE OFFENSE INCLUDE THE USE OR ATTEMPTED USE OF PHYSICAL FORCE, OR THREATENED USE OF A DEADLY WEAPON? Yes No Provide Subsection of Convicted Offense D. INSTRUCTION TO CLERK ­ ATTACHED DOCUMENTS DATE OF OFFENSE: Charging Documents CONVICTION DATE: Sentencing Order Mail this form and the above documents to: Illinois State Police, Firearms Services Bureau, 801 S. 7th Street, Ste. 400M, Springfield, IL 62703. AFFIRMATION BY THE COURT: (Please attach a certified copy of the conviction or certify this form.) The Clerk of the Court shall forward a copy of this form to the Department of State Police, Firearm Owner's Identification Department and place the original in the court file. Atty. No.: Name: Atty. for: Address: City/State/Zip Code: Telephone: Page 1 of 1 (Seal of Circuit Court Clerk) Dorothy Brown, Clerk of the Circuit Court DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS