ICE Directive 1005.2, ICE Form 30-009: Lautenberg Certification for ICE Directive 1005.2

DEPARTMENT OF HOMELAND SECURITY U.S.

Immigration and Customs Enforcement LAUTENBERG CERTIFICATION Directions: You must complete PART I and PART II of this form. You should review the statute and the accompanying fact sheet before completing the inquiry.

PART I.

Inquiry Have you ever been convicted of a misdemeanor crime of domestic violence within the meaning of 18 U.S.C. § 922(g)(9)? Initial and date: YES NO If you answered NO, skip to PART II of the form. If you answered YES, you should review the fact sheet before providing the information requested below and completing PART II of the form. Court/Jurisdiction: Docket/Case Number: Statute/Charge: Date Sentenced: PART II.

Certification I hereby certify that, to the best of my knowledge and belief, all of the information provided by me is true, correct, complete and made in good faith. I understand that a false statement on any part of this inquiry may be grounds for firing me. False or fraudulent information provided herein is also criminally punishable pursuant to federal law, including 18 U.S.C. § 1001. Print Name (Last) Signature (First) (Middle) Date Last four digits of Social Security Number xxx-xx- Privacy Statement Authority and Purpose: ICE is collecting this information to assess your eligibility to possess or receive firearms or ammunition as an ICE law enforcement officer.

Collection of this information is necessary to ensure ICE complies with 18 U.S.C. § 922(g)(9), which prohibits individuals convicted in any court of a misdemeanor crime of domestic violence from possessing a firearm or ammunition that has been shipped or transported in interstate or foreign commerce. The last four digits of your Social Security Number are requested in order to identify you and ensure that this form is maintained in the correct personnel file. The authority for collection of this information is 18 U.S.C. § 922. Disclosure: Furnishing this information is mandatory.

For current law enforcement officers, failure to provide this information will result in loss of eligibility to carry a firearm and may result in disciplinary action up to and including removal from a law enforcement officer position. Routine Uses: This information will be used within ICE to confirm that current law enforcement officers are not barred from carrying a firearm. ICE Form 30-009 (7/12) Page 1 of 1 REL0000021291