Form Sts 3 PDF Details

Form STS-3 is a four-page form used to report the actions of federal law enforcement officers that may have violated an individual's civil rights. This form is used by the Department of Justice (DOJ) to investigate and prosecute such violations. Completed forms are submitted to the DOJ's Civil Rights Division. Anyone can complete and submit a Form STS-3, but it is advisable to seek legal representation before doing so. By completing and submitting a Form STS-3, you may be strengthening your case and helping to ensure that those responsible are held accountable.

QuestionAnswer
Form NameForm Sts 3
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesnegligently, sts 003 nj, sts 003, SBI

Form Preview Example

This form is prescribed by the Superintendent for use by applicants for duplicate Firearms I.D. Cards. Any alteration to this form is expressly forbidden.

STATE OF NEW JERSEY

Application for Duplicate Firearms Purchaser Identification Card

All persons wishing to obtain a duplicate Firearms Purchaser Identification Card are required to complete this application form.

Check Appropriate Block(s)

Application to replace lost or stolen Identification Card

Application for change of address on Identification Card

Application to replace mutilated Identification Card

Application for change of sex on Identification Card

Application for change of name on Identification Card

 

List former name here and attach copy of marriage license or court order

(1) Last Name ( If female, include maiden) First

Middle

(2)Resident Address (Number - Street - City - State - Zip)

(3)

Date of Birth

 

(4) Age

(5) Distinguishing Physical Characteristics (Marks, Scars, Tattoos)

(6) U.S. Citizen

 

(7) Social Security Number

 

/

/

 

 

 

 

 

 

 

Yes

No

 

-

-

Month

Day

Year

 

 

 

 

 

 

 

(8)

Sex

Height

Weight

Eyes

Race

Hair

Complexion

(9) Driver's License Number & State

 

(10) Home Telephone

 

 

 

 

 

 

 

 

 

 

 

 

(

)

-

(11) Address Appearing on Former Card

(12) N.J. Firearms ID Card/ SBI number

(13)

Have you ever been adjudged

 

 

 

 

Yes

If Yes, List Date(s)

 

 

 

Place(s)

Offense(s)

 

 

 

 

 

 

 

 

 

 

 

a juvenile delinquent?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

(14)

Have you ever been convicted

 

 

 

 

Yes

If Yes, List Date(s)

 

 

 

Place(s)

Offense(s)

 

 

 

of a disorderly persons offense,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

that has not been expunged or

 

 

 

 

No

 

 

 

 

 

 

 

 

 

sealed?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(15)

Have you ever been convicted

 

 

 

 

Yes

If Yes, List Date(s)

 

 

 

Place(s)

Offense(s)

 

 

 

 

 

 

 

 

 

 

 

of a criminal offense, that has

 

 

 

 

 

 

 

 

 

 

 

 

 

 

not been expunged or sealed?

 

 

 

 

No

 

 

 

 

 

 

 

 

 

(16)

Have you ever had a firearms

 

 

Yes

If Yes, By Whom?

 

 

When?

Where

Why?

 

 

 

purchaser identification card,

 

 

 

 

 

 

 

 

 

 

 

 

 

permit to purchase a handgun,

 

 

 

 

No

 

 

 

 

 

 

 

 

 

or permit to carry a handgun

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

refused or revoked?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(17)

Have you ever had an

 

 

 

 

Yes

If Yes, By Whom?

 

 

When?

Where

Why?

 

 

 

 

 

 

 

 

 

 

Employee of Firearms Dealer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

License refused or revoked?

 

 

 

 

No

 

 

 

 

 

 

 

 

 

(18)

Are you an Alcoholic?

 

 

Yes

(19) Have you ever been confined or committed to a mental institution or hospital for treatment

or observation

 

 

Yes

 

 

 

 

 

 

No

of a mental or psychiatric condition on a temporary, interim or permanent basis? If Yes, give the name and

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

location of the institution or hospital and the date(s) of such confinement or commitment

 

 

 

No

(20)

Are you dependent upon the

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

use of any narcotic or other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

controlled dangerous substance?

 

 

 

 

No

 

 

 

 

 

 

 

 

 

(21)

Are you now being treated for

 

 

Yes

(22) Have you ever been attended, treated or observed by any doctor or psychiatrist or at any hospital or mental

 

 

Yes

 

 

 

 

 

 

 

 

a drug abuse problem?

 

 

No

institution on an inpatient or outpatient basis for any mental or psychiatric conditions? If Yes, give the name &

 

 

 

 

 

 

 

 

location of the doctor, psychiatrist, hospital or institution and the date(s) of such occurrence.

 

 

 

No

(23)

Do you suffer from a physical

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

defect or sickness?

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(24)

If answer to question 23 is yes, does this make it unsafe for you to

 

Yes

(25) Are you subject to any court order issued pursuant to Domestic

 

 

Yes

handle firearms? If not, explain.

 

 

 

 

 

No

Violence?

If yes, explain.

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(26)

Have you ever been convicted of any domestic violence in any jurisdiction which involved the elements of (1) striking, kicking, shoving, or (2) purposely or

 

 

Yes

attempting to or knowingly or recklessly causing bodily injury, or (3) negligently causing bodily injury to another with a weapon? If Yes, explain.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(27)Are you presently, or have you ever been a member of any organization which advocates or approves the commission of acts of violence, either to overthrow the government of the United States or of this State, or to deny others of their rights under the Constitution of either the United States or the State of New Jersey? If yes, list name and address of organization(s) here:

Yes No

APPLICANT: DO NOT WRITE BELOW THIS SPACE

A Request for a Criminal History Name Check (SBI 212A) must accompany this application along with the required fee payable to "Division of State Police SBI." Application must be made to the Chief of Police, in the municipality in which you reside or to the Superintendent in all other cases.

APPROVED

 

 

IDENTIFICATION CARD NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DISAPPROVED

Reason for Disapproval

 

 

 

 

 

A. CRIMINAL RECORD

 

 

 

 

 

B. PUBLIC HEALTH SAFETY AND WELFARE

 

 

 

 

 

 

 

 

 

 

C. MEDICAL, MENTAL OR ALCOHOLIC BACKGROUND

 

 

 

 

 

GRANTED ON

 

 

 

 

D. NARCOTICS/ DANGEROUS DRUG OFFENSE

 

 

 

APPEAL

 

 

 

 

 

E. FALSIFICATION OF APPLICATION

 

 

 

 

 

 

 

 

 

 

 

 

 

F. DOMESTIC VIOLENCE

 

 

 

 

 

 

 

 

 

 

G. OTHER (SPECIFY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I hereby certify that the answers given on this application are complete, true and correct in every particular. I realize that if any of the foregoing answers made by me are false, I am subject to punishment.

(28)

Signature of ApplicantDate of Application

(The disclosure of my social security number is voluntary. Without this number, the processing of my application may be delayed. This number is considered confidential.)

Falsification of this form is a crime of the third degree as provided in NJS 2C:39-10c.

APPLICANT: DO NOT WRITE BELOW THIS SPACE

This

Day of

, 20

 

 

 

 

 

 

 

 

Signature

 

 

 

Title

STS-3 (Rev 09/06)

Department of Police

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