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. t “Department of tho Treesury ‘internal Revenue Service * Aleohol, “ubrece and . % ua atra- Stale Over-the-Counter” co : Pisent read und tocetety | tetton the bert actlos on foe se, ‘Section A—Stalement of Transferce or Buyer “Lh “Tl. Teansferce’ s (buyer's) name (last, first, eniscte) Ga. Mio Mi “Are you z fypitive fram Justice? == -B. Certification of Transicree (Buyer}—an vntrathtul answer | c anzy subject you to eriminal prosecution, Each question must - gd Are you .an -unlawiul aser of, oF “padicléd “te: mari + “be answered with @ yes or no. : " huanz or .a ‘Mepressent,. “stimulant, © Of. eetcolc a. Are you under indictment in any court for a ¢rimo | “ "grup? - : punishable Ly imprisonment for a lerm exceeding ono "Have you been, adjudicated mentally detective sor have | your mo you , ever been committed | ‘8 mente institu. “p. Have you been convicted in any court of a crime . _ punishable by imprisonment for a term exceeding cne - ‘€. Have -you boen discharged “trom: ‘tno. Asmed Forces ~ year? (Hote: The aclual sentence given by the judge ,.. ,under dishonorable conditions? ———___ “st "goes not matter—e yes answer is necessary # the. 2 4 Are you an alien illegally in the United | States? we qudee could have given a sentence of more than one 1.5 | Are you & person ‘who; having dren a Citizen of Ate year.) ——..— ‘United States, has renounced his citizenship? e—reecen | _ 2 hereby certify {hat the answers to the above are true and thst the making of sny false oral er written stat tement “or dhe -@trrect. | understand that 8 person who answers any of the exhibiting of any false or misrepresented Identification with | above questions in the effirmeative is prohibited by Federal law respect to this t transaction i 4 crime ® punishable as a a telony. | rom purchasing aad/or possessing a firearm. t also understand . fEe ye eet a . Franetoree'e (buyer's) signature Section B8-—-Stalement of Transteror ‘or Seller “The person described in Section A, ts known to me O, of has identified hinrself to me © In the foftowing manner: - : a 9 Type of identification (driver's license, etc.) 10. Number on identification On the besis of (3) the statements in Section A; (2) the verifi- not unlavdtul for me to sell, deliver, or othenvise dispose of the tation of identity noted In Section B; and (3) the information in firearm described below to thea person identified in Seclion A. the cunent list of Published Ordinances, it is my belief that it is . : . Loy: 12. Model 13. Caliber or gauge | 34. Seriat number - 15. Monutactoer (and importer, if any) 7 nie FEE. ; ' 46. a 8) signature