Santa Clara — CV-5103/ FM-1200*

Source: https://santaclara.courts.ca.gov/system/files/forms/cv-5103_fm-1200_rem.pdf

ATTACHMENT CV-5103/FM-1200 SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA FOR COURT USE ONLY STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME:

PROTECTED PERSON:

RESTRAINED PERSON:

CASE NUMBER:

DECLARATION REGARDING RESTRAINED PARTY’S FIREARMS

1. Does the Restrained Party own or have access to firearm(s)? Yes No Unknown ☐ ☐ ☐
2. Does the Restrained Party have a license to carry a concealed weapon (CCW)? Yes No Unknown ☐ ☐ ☐
3. When was the last time you saw the firearm(s)?_________________________

4. Do you know where the Restrained Party keeps the firearm(s)? ☐ Yes No Unsure ☐ ☐
They are usually kept: (all that apply)

On their Person In their Car In their Home Storage Unit In a Safe ☐ ☐ ☐ ☐ ☐
Other:__________________________________________________________

5. Has the Restrained Party used the firearm to threaten or intimidate you? Yes No ☐ ☐
• When did they last threaten you with it?_________________________

• Did you report the incident to the police? Yes No ☐ ☐
• Which law enforcement agency?______________________________

6. On a scale from 1 to 5 (1 being “not very important” and 5 being “very important”), how important are firearms to
the Restrained Party?

1 2 3 4 5 ☐ ☐ ☐ ☐ ☐
7. What does the Restrained Party generally use the firearm for? (all that apply)

☐ Hunting ☐ Collecting Target Shooting Protection Other:_____________ ☐ ☐ ☐

8. Does the Restrained Party possess explosives? Yes No Unknown ☐ ☐ ☐

CV-5103/FM-1200 REV 07/01/2024 DECLARATION REGARDING RESTRAINED PARTY’S FIREARMS Page 1 of 3 For Mandatory Use

9. Has the Restrained Party ever ordered parts of firearms or does the Restrained Party possess parts that could be assembled into a working firearm? Yes No Unknown ☐ ☐ ☐

   10. Has the Restrained Party ever posted photos or videos on social media of firearms? Yes (you may attach ☐ screen shots of this) No Unknown ☐ ☐ If so, what is/are the social media handle(s)__________________________________________

   11. The following pictures are examples of the most common types of guns. If you recognize any of the guns below as similar to the one(s) the Restrained Party has, please indicate it and write the number of how many you think they have.

       Semi-automatic Handgun Number: ____________ ☐ ☐

       Revolver Number: ____________ ☐ ☐

       Shotgun Number: ____________ ☐ ☐

CV-5103/FM-1200 REV 07/01/2024 DECLARATION REGARDING RESTRAINED PARTY’S FIREARMS Page 2 of 3 For Mandatory Use

Rifle Number: ____________ ☐ ☐

Semi-automatic Rifle Number: ____________ ☐ ☐

I declare under penalty of perjury under the laws of the state of California that the foregoing is true and correct.
Date:

_____________________
Print Name Signature

CV-5103/FM-1200 REV 07/01/2024 DECLARATION REGARDING RESTRAINED PARTY’S FIREARMS Page 3 of 3 For Mandatory Use