State of Connecticut

For NTC use only

Department of Public Safety

Firearm Tracing & Identification

Pursuant to Sec. 54-36n C.G.S., print or type and submit form on date if seizure, retaining original copy in the incident file.
FAX to the Statewide Firearms Trafficking Task Force @ (203) 630-8082
1a. Date of Request

PART I TRACE INITIATION INFORMATION

Routine
Urgent (if urgent, check on or more of the following boxes)
Robbery
Kidnapping
Murder/Suicide
Rape/Sexual Assault
Terrorist Threat
Other (specify)
PART II CRIME CODE INFORMATION
Juvenile Involved?
Entered Into NIBN/DRUGFIRE?
Yes
Yes\
No
No
PART IV OTHER AGENCY REQUESTING TRACE (PART III WAS OMITTED)
4b. Agency Contact Numbers
4c. Agency Officers Name
4d. Badge Number

1b. Priority
Assault
Terrorist Act

2a. Gang Involved?

Yes Name of Gang:
No
4a. ORI Number (NCIC)
4e. Agency Case Number
5a. Serial Number

5d. Caliber

4f. Department/Unit

4g. Agency Mailing Address

PART V FIREARMS INFORMATION (verify date in 52-53 & 5h)

Attempted to Raise Obliterated
None
5b. Firearm Manufacturer
5c. Type (code letter only, see
below)
5e. Model

5h. Any Additional Markings

5i. Imported By

5j. Country of Origin

6A. Name

(Last)

PART VI POSSESSOR IDENTIFICATION

(First)
(Middle)
(Suffix)

ALIAS (AKA)

(Last)

(First)

(Middle)

6b. Criminal History?

Yes
No
AKA Date of Birth

(Suffix)

6b. Height

6c> Weight

6d. Sex

6e. Race

6f. Address Route No.

6g. Apt. No.

6h. Street No.

6i. Direction

6j. Street Name

6k. City

6l. County

6m. State

6n. Zip Code

6o. Country

6p. Date of Birth

6q. Place of Birth

6r. Possessors ID NO.

6s. ID Type/State

7A.. Name

(Last)

PART VII ASSOCIATE INFORMATION

(First)
(Middle)

(Suffix)

ALIAS (AKA)

(Last)

(First)

(Suffix)

(Middle)

6b. Criminal History?

Yes
No
AKA Date of Birth

7b. Height

7c. Weight

7d. Sex

7e. Race

7f. Address Route No.

7g. Apt. No.

7h. Street No.

7i. Direction

7j. Street Name

7k. City

7l. County

7m. State

7n. Zip Code

7o. Country

7p. Date of Birth

8a. Recovery Date
8g. City

7q. Place of Birth

7r. Associates ID NO.

7s. ID Type/State

PART VIII FIREARM RECOVERY INFORMATION (confirm recovery data in 8a, 8g & 8h)
8b. Route No.
8c. Apt. No.
8d. Street No.
8e. Direction
8h. State

8i. Zip Code

8j. Additional Information

8f. Street Name

Letter codes for Questions 5c. Type are as follows: C= Combination has both rifled & smooth bore barrels; M= Machines Gun fires more than one shot with a single
trigger pull; P+ Pistol, single shot or semiautomatic handgun with integral aligned chamber & barrel; P/R = Pistol/Derringer, small handgun with hinged or pivoting
barrel(s), R = Rifle, long gun with smooth bore barrel(s).

DPS-258-C (Revised 8/07)