Sonoma — Prohibited Persons Relinquishment Report

Source: https://sonoma.courts.ca.gov/system/files/forms-and-filings/final-fr-110.pdf

Sonoma County Superior Court FR-110 Mental Health Diversion Prohibited Persons Relinquishment Form (Welfare and Institutions Code § 8103)

The below defendant is prohibited from purchasing, owning, or possessing Firearms, Firearm Parts, Ammunition, Magazines, and any body armor in their possession personally or via a consenting third party (Power of Attorney or Designated Law Enforcement Designee) pursuant to Welfare and Institutions Code § 8103).

Any reference to “firearm” throughout this form includes any firearms (guns), receivers, frames, and any item that may be used as or easily turned into a receiver or frame (see Welfare and Institutions Code § 8103).

A. Prohibited Person Information (MHD Participant): Last Name: First Name: Middle Name:

Physical Residence Address: City: State: Zip Code:

Date of Birth (mm/dd/yyyy): California Driver License or Identification No.: Sex: Phone No. (include area code):

B. Firearm(s) Information (To report additional firearm(s), use supplemental form (FR-111):

I do not own, possess, or have under my custody or control, any firearms, ammunition or ammunition feeding devices, including but not limited to magazines.

Signature Date

Firearm Type: Serial Number: Make: Model:

☐ Handgun ☐ Rifle ☐ Shotgun

Caliber: Color: Firearm Origin: Barrel Length: ☐ In. Category (i.e. semi-automatic, single-shot, bolt action):

☐ Cm.

Describe Firearm (Identification Marks):

Current Location of Firearm (including address and other information about the firearm's specific location):

Firearm Type: Serial Number: Make: Model:

☐ Handgun ☐ Rifle ☐ Shotgun

Caliber: Color: Firearm Origin: Barrel Length: ☐ In. Category (i.e. semi-automatic, single-shot, bolt action):

☐ Cm.

Case Number: _________________________

Sonoma County Superior Court FR-110 Mental Health Diversion Prohibited Persons Relinquishment Form (Welfare and Institutions Code § 8103)

Serial Number: Make: Model: Firearm Type:

☐ Handgun ☐ Rifle ☐ Shotgun

Caliber: Color: Firearm Origin: Barrel Length: ☐ In. Category (i.e. semi-automatic, single-shot, bolt action):

☐ Cm.

Describe Firearm (Identification Marks):

Current Location of Firearm (including address and other information about the firearm's specific location):

Firearm Type: Serial Number: Make: Model:

☐ Handgun ☐ Rifle ☐ Shotgun

Caliber: Color: Firearm Origin: Barrel Length: ☐ In. Category (i.e. semi-automatic, single-shot, bolt action):

☐ Cm.

Describe Firearm (Identification Marks):

Current Location of Firearm (including address and other information about the firearm's specific location):

Initial By initialing here, I understand my legal responsibilities to also complete a Receipt for Firearms, Firearm Parts, Ammunition, and Magazines form FR-120.

By initialing here, I understand that any person who lives with me (cohabitant) and who owns firearms must store those firearms in accordance with Penal
Code section § 25135

Initial

C. Court Authorized Exception(s):

☐ Yes ☐ No The court has approved a shortened or enlarged relinquishment time period or has allowed for an alternative method for relinquishment (If checked "yes," attach court documentation).

D. Power of Attorney (Consenting Third-Party)/Law Enforcement Designee Assignment: I, ________________________, hereby designate ___________________________ to have Power of Attorney for the purpose of transferring or disposing of my firearm(s).

Printed Name of MHD Participant Printed Name of Power of Attorney/LEA Designee

E. Defendant Declaration:

As the firearm owner, I hereby declare, under penalty of perjury under the laws of the State of California, that the foregoing is true and correct. I understand that l, as defendant, and/or the designee are obligated to submit a completed Reciept for Firearms, Firearm Parts, Ammunition, and Magazines form (FR-120) to the court within the specified time period.

I have been released from law enforcement custody and understand I myself or my designee shall dispose of any firearms I own, possess, or have in my custody or control
following the granting of pretrial mental health diversion.

Signature Date

Case Number: _________________________

Sonoma County Superior Court FR-110 Mental Health Diversion Prohibited Persons Relinquishment Form (Welfare and Institutions Code § 8103)

F. Power of Attorney Designee (Consenting Third-Party): Last Name: First Name: Middle Name:

Physical Residence Address: City: State: Zip Code

Date of Birth (mm/dd/yyyy): California Driver License or Identification No.: Sex: Phone No. (include area code):

I, ________________________, hereby agree to accept appointment as Power of Attorney for the purpose of transferring or disposing firearm(s) on behalf of Printed Name of Power of Attorney Designee

the owner or possessor of the firearm(s).

Printed Name of Defendant

I understand that it is my legal responsibility to carry out one of the following actions on behalf of the defendant: surrender the firearms to the control of a local law enforcement agency, sell the firearms to a licensed firearms dealer or transfer the firearms to a dealer. I understand that I, the designee, shall relinquish the firearm(s) that were in the possession of the mental health diversion participant. I understand that I am obligated to submit this completed FR-110 form to the court. In addition, I shall state the date each firearm was relinquished and the name of the party to whom it was relinquished to and attach corresponding receipts, or the optional Firearm Disposition Receipt Form (FR-112), from the law enforcement agency or licensed firearms dealer who took possession of the relinquished firearm(s). I declare under penalty of perjury under the laws of the State of California, that I am not prohibited by law from possessing firearms.

Signature Date

G. Power of Attorney Designee (Law Enforcement Agency):

ORI Number: LEA Name:

Street Address: City: State: Zip Code: Phone Number:

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Printed Name of LEA Signature Date

Case Number: _________________________

Sonoma County Superior Court FR-110 Mental Health Diversion Prohibited Persons Relinquishment Form (Welfare and Institutions Code 8103)

H. Firearm Relinquishment Information (Attach completed FR-112 Form(s) and/or Receipts)

Serial Number: Make: Model: Firearm Type:

☐ Handgun ☐ Rifle ☐ Shotgun Caliber: Color: Firearm Origin: Barrel Length: ☐ In. Category (i.e. semi-automatic, single-shot, bolt action):

☐ Cm.

Describe Firearm (Identification Marks):

Firearm Relinquished to: ☐ Law Enforcement Agency (LEA) _________________________________________________ ___________________________ ORI No., LEA Name, and Address Relinquished Firearm Date ☐ Licensed Firearm Dealer _____________________________________________________ ___________________________ CFD. No., Name, and Address Relinquished Firearm Date

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Print Name and Title of LEA Representative or CFD Salesperson/Associate Signature of LEA Representative or CFD Salesperson/Associate

Firearm Type: Serial Number: Make: Model:

☐ Handgun ☐ Rifle ☐ Shotgun Caliber: Color: Firearm Origin Barrel Length: ☐ In. Category (i.e. semi-automatic, single-shot, bolt action):

☐ Cm.

Describe Firearm (Identification Marks):

Firearm Relinquished to: ☐ Law Enforcement Agency (LEA) _________________________________________________ ___________________________ O ORI No., LEA Name, and Address Relinquished Firearm Date

☐ Licensed Firearm Dealer (CFD) __________________________________________________ ___________________________ CFD. No., Name, and Address Relinquished Firearm Date

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Print Name and Title of LEA Representative or CFD Salesperson/Associate Signature of LEA Representative or CFD Salesperson/Associate

Serial Number: Make: Model: Firearm Type:

☐ Handgun ☐ Rifle ☐ Shotgun Caliber: Color: Firearm Origin: Barrel Length: ☐ In. Category i.e. semi-automatic, single-shot, bolt action): ☐ Cm. Describe Firearm:

Firearm Relinquished to: ☐ Law Enforcement Agency (LEA) _________________________________________________ ___________________________ O ORI No., LEA Name, and Address Relinquished Firearm Date

☐ Licensed Firearm Dealer (CFD) __________________________________________________ ___________________________ CFD. No., Name, and Address Relinquished Firearm Date

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Print Name and Title of LEA Representative or CFD Salesperson/Associate Signature of LEA Representative or CFD Salesperson/Associate

Case Number: _________________________