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Internal Control Number National Firearms Act Branch SUBMIT in DUPLICATE to: Bureau of Alcohol, Tobacco, Firearms and Explosives, 244 Needy Road, Martinsburg, WV 25405 2a. Transferee's Name and Address (Include trade name, if any) (See instruction 2d) 1. 2b. 3a. 3c. I Believe That I am Entitled to Exemption From the Payment of the Transfer Tax Imposed By Section 5811 (26 U.S.C. Chapter 53) on the Firearm Described Herein for the Following Reason (See Instruction 2b): Firearm is Unserviceable.

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