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NYS Firearms License Request for Public Records Exemption~5S OFFICE OF THE ~~' COUNTY CLERK OF DUTCHESS COUNTY a '~ ,.'`« Poughkeepsie, New York 12601 (845)486-2130 Bradford H. Kendall Bryan F. Cranna Sandra Strid County Clerk Deputy County Clerk Deputy County Clerk MEMORANDUM February 15, 2013 Thank you for contacting the County Clerk's Office about the opt out provision for pistol licensees. I have attached a PDF file of the form that you may print and use. You may also access the form at the following link: http://www.troopers.ny.,gov/Firearms/Public Records Exemption/FOIL Exemption Form pdf Once you have completed the form please return it by mail or in person to: Bradford Kendall Dutchess County Clerk 22 Market St. Poughkeepsie, NY 12601 We cannot accept fax copies or email transmissions of scans as the form must contain an original signature. Currently all pistol license records are sealed until at least May 15, 2013. We will need to modify our record system to accommodate this new unfunded mandate on County Clerk's. Until those modifications are in place records will continue to be sealed but in no event will that be before May 15, 2013. NYS Firearms License Request for Public Records Exemption Pursuant to seclion 400.00 (5) (h) of the NYS Penal Law I am: [ ] an applicant for a firearms license [ ]currently licensed to possess a firearm in NYS Name Address Firearms License # (if applicable) Licensing Authority / County of Issuance or Application Date of Birth City State Date Issued I hereby request that any information concerning my firearms license application or firearms license not be a public record. The grounds for which I believe my information should NOT be publicly disclosed are as follows: (check all that are applicable) [ j 1. My life or safety may be endangered by disclosure because: [ ] A. I am an active or retired police officer, peace officer, probation officer, parole officer, or corrections officer; [ ] B. I am a protected person under a currently valid order of protection; [ ] C I am or was a witness in a criminal proceeding involving a criminal charge; [ ] D. I am participating or previously participated as a juror in a criminal proceeding, or am or was a member of a grand jury; [ ] 2. My life or safety or that of my spouse, domestic partner or household member may be endangered by disclosure for some other reason explained below: (Must be explained in item S below) ( ] 3. I am a spouse, domestic partner or household member of a person identified in A, B, C or D of question 1. (Please check any that apply) A B C D [ 1 4. I have reason to believe that I may be subject to unwarranted harassment upon disclosure. 5. (Please provide any additional supportive information as necessary) I understand that false statements made herein are punishable as a class A misdemeanor. I further understand that upon discovery that I knowingly provided any false information, I may be subject to criminal penalties and that this request for an exemption shall become null and void. Signature Date