I do hereby authorize a review and full disclosure of all records concerning myself, as required by Iowa Code Ch. 724 and Iowa Administrative Code 661—Ch 91, to any duly authorized agent of an Iowa sheriff or the Commissioner of the Iowa Department of Public Safety, whether the said records are of a public, private or confidential nature.
The intent of this authorization is to give my consent for full and complete disclosure of records of psychiatric treatment, substance abuse treatment, consultation and/or court ordered involuntary committal for treatment including those records held by hospitals, clinics, private practitioners, the U.S. Veteran’s Administration and clerks of court, as necessary to verify that I meet the requirements of the state of Iowa and the United States for the acquisition and possession of a firearm. I understand that the information contained in these records will be used for no purpose other than those stated above, and will be kept strictly confidential by the office of the issuing official.
I understand that any information obtained which is developed directly or indirectly, in whole or part, upon this release authorization will be considered in determining my qualification for obtaining a permit to acquire pistols/revolvers in the state of Iowa. I also certify that any person(s) who may furnish such information concerning me shall not be held accountable for providing accurate information, and I do hereby release said person(s) from any and all liability which may be incurred as a result of furnishing such information.
I certify that all information, including supporting documentation, provided in this application is true and correct, and I understand that I may be convicted of a class “D” felony pursuant to Iowa Code section 724.17 if I make what I know to be a false statement of material fact on this application or if I submit what I know to be any materially falsified or forged documentation in connection with this application.