In the Court of Common Pleas of ______________ County,

Civil Division
In Re: Case No. ________________
Applicant’s Name
Applicant’s Address

Application for Relief from Statutory Disability to Possess a Firearm

I, _____________, apply to the Court for relief from the statutory disability to possess a firearm.
This application is submitted pursuant to Ohio Rev. Code 2923.14. I, ______________, assert that
all the requirements for granting relief from disability listed in Ohio Rev. Code 2923.14(B) and
2923.14(D) have been satisfied, and that an order should be issued, upon hearing, granting relief
from disability based upon the following findings which are supported by the attached affidavit.

1. Applicant currently resides in ____________ County, which is the same County in which this
application is being filed.

2. The following is a list of all indictments, convictions, or adjudications upon which Applicant's
disability is based.
Applicant was convicted of the following offense(s) ______________ on the date of
________with the case number of ______________, in the Court of __________, in
___________County, with the following sanctions_______________________________.
Applicant was adjudicated of the following offenses ______________ on the date of
________with the case number of ______________, in the Court of __________, in
___________County, with the following sanctions_______________________________.
Applicant is currently under indictment for the following offense
(s)___________________________.

3. Applicant’s probation was terminated on the date of __________________________and s/he

was fully discharged from parole, post-release and/or community control sanctions.

4. The Applicant is not otherwise prohibited by law from acquiring, having or using firearms.

5. The Applicant has led a law-abiding life since his/her discharge from community control and
appears likely to continue to do so based on the facts set forth in the attached affidavit.
 Affidavit

I, ____________________, declaring to be a resident of the state of Ohio and County of

___________, do hereby affirm and certify that I am competent to give the following
declarations based on my personal knowledge, unless otherwise stated, and that the facts are as
follows:

WITNESS my signature this _____day of __________(year and month).

__________________

Affiant

_____________________
Notary Public
 Certificate of Service

I certify that a copy of the attached document was mailed to (the County
Prosecutor)________________________________________, by regular U.S. Mail to (Street
Address)_____________________________________________________, (City, State, Zip
Code) ____________________________________________________________,on (Date)
_____________________________.

_______________________
Signature