ACKNOWLEDGMENT OF PERSON

ACKNOWLEDGMENT OF PERSON AGREEING TO SAFEGUARD FIREARMS) P01.24012 (tif-, 12-111 Name of Applicant / Licen Application / License Num Instruction to Applicant/Licensee; Please ask the person you have designated to safeguard and surrender your firearm(s) in the event of your death or incapacity to complete the information below and sign this acknowledgment before a witness (The p Print Addre Tele • (rant name c7-;:erson a understand that the above-named applicant'licensee has designated me to safeguard and surrender his/her firearm(s) in the event that he 'she dies or becomes incapacitated. I agree that upon learning of the death or incapacity of the licensee. I will immediately notify the New York City Police Department's License Division at (646) 610-5871 or (646) 610-5560. or by calling the local police precinct, and will follow their directions to safeguard and surrender his/her firearm(s). Signature of person agre to safeguard firearm(s): Witnessed by (signature)' Witness' Name (printed Nens: ret2!!! cop:' t .: decummt for yet!r ry.erdE Dater-1 r -D 12- EFTA00556958