Kentuckystatepolice.org – The Thin Gray Line



CCDW LICENSE CITIZENSHIP/IMMIGRATION STATUS AFFIDAVIT

I, (please print) ________________________________________________________________, am applying for issuance or renewal of a Carry Concealed Deadly Weapons (CCDW) license pursuant to Kentucky Revised Statute (KRS) 237.110. I hereby certify, as evidenced by my signature on page 2 of this document, that: I have read KRS 237.110 and attest that I am eligible to be issued a CCDW license; I have read Title 18 , Section 922 of the United States Code (18 U.S.C. 922) and attest that I am eligible to possess a firearm under federal law; that my responses to the following questions are executed under oath; and that a materially false answer to any question or the submission of any materially false document subjects me to criminal prosecution under KRS 523.030.

PLEASE PRINT YOUR ANSWERS TO THE FOLLOWING QUESTIONS:

1) What is your country of citizenship? _________________________________________.

2) Do you have a driver’s license? (yes/no) _______________.

3) If your answer to Question 2 was yes, please state the license number and which government (state, territory or country) it was issued by: _______________________________________________________________________.

4) If your answer to Question 2 was no, do you have a personal identification card issued to you by the office of the circuit clerk of the county where you reside? (yes/no) _________.

5) If your answer to Question 4 was yes, please state your personal identification card number: ________________________________________________________________.

6) What is your Passport Number? _____________________________________________.

7) What is your mother’s maiden name? ________________________________________.

8) What is your father’s last name? _____________________________________________.

9) Are you a permanent resident alien of the United States? (yes/no) _________________________.

If your answer to Question 9 was yes, please respond to Question 10, but you will not be required to respond to Questions 11-13. However, you will need to complete and sign the first portion of the Affidavit below before a Notary Public, who must notarize your signature.

If your answer to Question 9 was no, skip to Questions 11-13.

10) What is your United States government issued alien number or admission number? _______________________________________________________________________.

11) If you are a nonimmigrant alien, what is your Visa Number? _______________________________________________________________________.

12) If you are a nonimmigrant alien, what was your Port of Entry into the United States? _______________________________________________________________________.

13) If you are a nonimmigrant alien, do you fall within any of the exceptions set forth in 18 U.S.C. 922(y)(2)? (yes/no) _____________________ . If you answered yes, you must attach copies of the documents showing an exception to the federal nonimmigrant alien prohibition (e.g. hunting license; waiver). Please complete and sign the first portion of the Affidavit before a Notary Public, who must notarize your signature.

Affidavit

IN WITNESS WHEREOF, the undersigned individual has executed this affidavit on this _____ day of __________________________ (Month), _______________ (Year).

_______________________________________________________________________

Affiant Signature

The foregoing instrument was sworn to and acknowledged before me by the above named individual this ______day of ________________ (Month), _______________ (Year).

| |My commission expires: | |

|Notary Public, State at Large | | |

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