IN THE ________ JUDICIAL CIRCUIT COURT, __________________________, MISSOURI Judge or Division: Case Number: Court ORI Number: Denied Applicant: SSN (Last Four Digits): vs. Sheriff: (Date File Stamp) Appeal of a Denial or Refusal to Act on a Concealed Carry Permit Small Claims Court The denied applicant states in regard to his/her properly completed application for a concealed carry permit filed on ___________________ (date), the sheriff of _____________________________ County, Missouri: denied the application without just cause. A copy of the sheriff's written denial is attached. The denied applicant affirms that all of the statements in the application are true. refused to act on the application filed on ___________________ (date) within forty-five days. Within the original application, I affirmed the following to be true: 1. Personal Information: Name:__________________________________________________________________________ Address: _______________________________________________________________________ Telephone Number: ______________________________________________ Male Female Date of Birth: ______________________________________________ Place of Birth: ______________________________________________ 2. I am 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. 3. I am a citizen of the United States. I am a permanent resident of the United States. Country of citizenship: _________________________ Alien or Admission number issued by the Federal Bureau of Customs and Immigration Enforcement or any successor agency: ______________________________________ 4. I have resided in this state for at least six months prior to issuance of the permit or qualify as a military member or spouse of a military member stationed in Missouri. OSCA (10-14) SC90 1 of 2 571.114 RSMo American LegalNet, Inc. www.FormsWorkFlow.com 5. I have not pled guilty to, entered a plea of nolo contendere or 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 involved an explosive weapon, firearm, firearm silencer, or gas gun. 6. I have not been convicted of, pled guilty to or entered a plea of nolo contendere to any misdemeanor offenses involving crimes of violence within the five-year period immediately preceding my application for a concealed carry permit pursuant to section 571.101, RSMo, nor have I been convicted of two or more misdemeanor offenses involving driving while under the influence of intoxicating liquor or drugs or possession or abuse of a controlled substance within the five-year period immediately preceding my application for a concealed carry permit pursuant to section 571.101, RSMo. 7. I am not 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 involved an explosive weapon, firearm, firearm silencer, or gas gun. 8. I have not been discharged under dishonorable conditions from the United States armed forces. 9. I am not reasonably believed to be a danger to myself or others by the sheriff based on any previous pattern of behavior documented in public or closed records. 10. I have not been adjudged mentally incompetent at the time of application or for five years prior to application, or been committed to a mental health facility, as defined in section 632.005, RSMo, or a similar institution located in another state, except that any release or discharge from a facility in this state pursuant to chapter 632, RSMo, or a similar discharge from a facility in another state, occurred more than five years ago without subsequent recommitment. In addition: 1. I submitted and cleared the required State of Missouri and/or national criminal history record checks. 2. I submitted an affidavit attesting that I complied with the concealed carry safety training requirement pursuant to section 571.111, RSMo. 3. I am not subject to a full order of protection which is still in effect. 4. I am not otherwise prohibited from possessing a firearm under section 571.070, RSMo, or 18 U.S.C. 922(g). 5. I submitted a government-issued photo identification to verify my identity. I swear/affirm under penalty of perjury that these facts are true according to my best knowledge and belief. __________________________________________ Date ____________________________________________ Denied Applicant OSCA (10-14) SC90 2 of 2 571.114 RSMo American LegalNet, Inc. www.FormsWorkFlow.com