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Pistol Permit Opt Out Form

  1. Pursuant to section 400.00 (5) (b) of the NYS Penal Law

  2. I am:

  3. The grounds for which I believe my information should Not be publicly disclosed are as follows: (check all that are applicable)

  4. My life or safety may be endangered by disclosure because:

  5. 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 with additional information below)

  6. 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)

  7. 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.

  8. ___________________________________________

  9. Pistol Permit PO Box 128 Mayville, NY 14757

  10. Leave This Blank: