F.C.A. §842-a Form 8-6 (Family Offense - Order and Notice to Law Enforcement Agency - Firearms Licenses and Surrenders) (8/2010) At a term of Family Court of the State of New York, held in and for the County of , at New York on , . P R E S E N T: Hon. Judge _______________________________ In the Matter of Petitioner, -against- Docket No. ORDER - FIREARMS LICENSES AND SURRENDERSNOTICE TO LAW ENFORCEMENT AGENCY Respondent. Date of Birth: _______________________________ TO: NEW YORK STATE POLICE1 LOCAL POLICE AUTHORITY [Specify]: An (order of protection)(temporary order of protection) under Article 8 of the Family Court Act having been issued by this Court on , and this Court having made findings in accordance with Section 842-a of said Act, PLEASE TAKE NOTICE THAT [Check applicable box(es)]: ” The Respondent has been ordered to surrender any and all firearms owned or possessed, including, but not limited to, the following [specify]: ____________________________________ 1 This form must be sent to local law enforcement agencies in all cases involving firearms surrender or fire arms license suspension, revocation or ineligibility orders. Additionally, where a firearms license revocation, suspension, ineligibility or surrender order is vacated or modified, this form must also be sent to the New York State Police, Pistol Permit Section, Public Security Building, State Campus Building #22, 1220 Washington Avenue, Albany, NY 12226-2252. Notification to the statewide registry of orders of protection regarding the issuance of orders of protection containing firearms conditions will suffice as notice to the New York State Police at the stage of issuance of the order of protection. American LegalNet, Inc. www.FormsWorkFlow.com Form 8-6 page 2 ________________________________________. Such surrender shall take place on or before [specify date/time]: ________________at:[specify location]:2______________________________ _________________________________________________; (and). ” The Respondent's license to carry, possess, repair, sell or otherwise dispose of a firearm or firearms, if any, pursuant to Penal Law §400.00, has been ” permanently revoked3 ” suspended until [specify date of expiration of order of protection or temporary order of protection]: ” The Respondent shall remain ineligible to receive a firearm license until [specify date of expiration of order of protection or temporary order of protection]: , unless extended by this Court; (and)(or) ” The order of this Court, dated , ” directing the surrender of firearm ” suspending Respondent's firearms license, if any ” revoking Respondent's firearms license, if any ” directing that Respondent shall be ineligible to receive a firearms license) has been: ” VACATED ” MODIFIED as follows [specify]: ” AND IT IS HEREBY ORDERED THAT the law enforcement agency to whom such surrender is to be made shall report back to this Court regarding Respondent's compliance with the order of surrender by [specify date]: ” AND IT IS FURTHER ORDERED THAT: ENTER ______________________________ JUDGE OF THE FAMILY COURT PURSUANT TO SECTION 1113 OF THE FAMILY COURT ACT, AN APPEAL FROM THIS ORDER MUST BE TAKEN WITHIN 30 DAYS OF RECEIPT OF THE ORDER BY APPELLANT IN COURT, 35 DAYS FROM THE DATE OF MAILING OF THE ORDER TO APPELLANT BY THE CLERK OF COURT, OR 30 DAYS AFTER SERVICE BY A PARTY OR THE ATTORNEY FOR THE CHILD UPON THE APPELLANT, WHICHEVER IS EARLIEST. Date: , . Check applicable box: 9 Order mailed on [specify date(s) and to whom mailed]:_______________________ 9 Order received in court on [specify date(s) and to whom given]: _______________ 2 In New York City, Respondent may be directed to surrender firearms at any New York City Police Department precinct. 3 Permanent revocation is authorized for final orders of protection and dispositions upon violations of orders of protection only. See F.C.A. §842-a. American LegalNet, Inc. www.FormsWorkFlow.com