Page 44 - 4473 Participant Guide ver 5.1 12.9.16.doc

SWORN STATEMENT

SHOP NO. _________
LOAN NO. _________
GUN NO. __________

In connection with the undersigned's redemption of the pawned firearm
described on the pawn ticket referenced above, the undersigned, under penalty of
perjury, hereby swears as follows:

1) I have obtained the above referenced pawn ticket for value;

2) I am obtaining the firearm described on the pawn ticket for personal use
and lawful purposes;

3) I will not, under any circumstances, deliver said firearm to the original
pawn customer, ______________________, (“Pledgor”), or to anyone who
occupies the same residence as the Pledgor, or anyone who may
be prohibited by law from obtaining or possessing said firearm which
would constitute a violation of the Federal Firearms law;

4) I understand that if I violate Section 3 above I will be committing a Straw
Purchase which is prohibited by Federal and State law and may subject me
to criminal prosecution; and

5) I am accepting full responsibility for the firearm.

I HEREBY AFFIRM that the facts stated above are true.

Signature: ___________________

Printed Name:_________________

Date:________________________

Witness: _______________________

Printed Name: __________________
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Please contact First Cash’s Firearms Compliance Officer prior to the use of this form. Your Supervisor must also be notified.