Annual Certification of Army Materiel Status
Triennial Certification of Ceremonial Rifles
DUE: January 2015, January 2018, January 2021, etc.
1. I, the undersigned, hereby certify that the following serial numbered US Army owned rifles Conditionally Donated for ceremonial use on hand are:
Model Manufacturer Serial Number
Ex: M1903A3 Winchester 123456789
1. ___________________ _________________________ _____________________
2. ___________________ _________________________ _____________________
3. ___________________ _________________________ _____________________
4. ___________________ _________________________ _____________________
5. ___________________ _________________________ _____________________
6. ___________________ _________________________ _____________________
7. ___________________ _________________________ _____________________
8. ___________________ _________________________ _____________________
9. ___________________ _________________________ _____________________
10. ___________________ _________________________ _____________________
11. ___________________ _________________________ _____________________
12. ___________________ _________________________ _____________________
13. ___________________ _________________________ _____________________
14. ___________________ _________________________ _____________________
15. ___________________ _________________________ _____________________
2. In accordance with the Conditional Deed of Gift(s), AR 700-131 and Title 10 USC § 4683, I certify that the aforementioned U.S. Army ceremonial rifles are:
a. _____still required and used in the manner agreed upon in the original statement.
b. _____are unserviceable. Notarized statement by a licensed arms repair facility
is attached.
c. _____no longer required. Request the ceremonial rifle team provide disposition
instructions to return ceremonial rifles.
Triennial Certification of Ceremonial Rifles (Cont.)
3. I hereby further certify that:
a. Our veterans organization is still in good standing with our respective National Headquarters and our current membership strength is .
or
b. Our police department still maintains an active honor guard with a membership
strength of .
and
These weapons are properly safeguarded, are properly maintained, and are used solely for their intended purpose of performing funeral details and other ceremonies. I hereby certify that to the best of my knowledge and belief that a 100% inventory of all ceremonial rifles in our possession was performed and that the rifles listed above are the only rifles in this organization at this time and that all of my statements are true, correct, complete and made in good faith. I understand and acknowledge that concealing material fact and/or making a false statement is a violation of Title 18 USC §1001 and may result in the cancellation of the Conditional Deed for any US Army property on loan to my organization and is punishable by fine or imprisonment.
SIGNATURE:______________________________
NAME:___________________________________
(Typed or Printed)
TITLE:___________________________________
ORGANIZATION:__________________________
(Name)
__________________________
(Address)
__________________________
(City, State)
Notary Public Endorsement
COUNTY OF______________________________ STATE OF_____________________
I, the undersigned, certify that I am a duly commissioned, qualified, and authorized notary public. Before me personally and within the territorial limits of my warrant of authority, appeared the above named individual, who is known by me to be the person who is described herein, whose name is subscribed to, and who signed this Triennial Certification of Ceremonial Rifles and who, having been duly sworn, acknowledged that this instrument was executed after its contents were read and duly explained, and that such execution was a free and voluntary act and deed for the uses and purposes herein set forth.
IN WITNESS WHEREOF, I have hereunto set my hand and affix my official seal on this
_________Day of _________________________, 20_____.
_________________________________ My Commission expires: _________________
Notary Public
................
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