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 drivers 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 mothers maiden name? ________________________________________.
8) What is your fathers 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?
_______________________________________________________________________.
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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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Rev. 1/11
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