Request Firearms Surcharge Remittance Forms

1. The form shall be completed by the licensee/sheriff.
2. The form shall be completed in its entirety, and can be typewritten, computer generated, or printed in blue or black ink with a ballpoint pen. This form may be duplicated.
3. In accordance with 18 PA C.S. § 6111, this form shall be submitted within 14 days of a sale, transfer, or instantaneous records check. The licensee/sheriff shall enter the date span in the designated space on the form, e.g., 01/01/24 to 01/14/24. The form shall include any and all sales, transfers, or instantaneous record checks made during that time period, e.g., from 01/01/24 to 01/14/24. Should you have a date span that includes more than one calendar year, you must submit a separate form for each calendar year. Never list a date span that includes more than one year.
4. List the Surcharge amount ($3.00) and PICS background check fee ($2.00) on the Surcharge Remittance form. Do not add sales tax to these amounts.
5. Only one check or money order should be sent with each Surcharge Remittance form. Do not send several small checks.
6. The Application/Record of Sale form should not be submitted without the Surcharge Remittance form and check.
7. The last surcharge remittance form submitted for the year must always end with 12/31, regardless of the number of days reported. All records for the previous year must be submitted no later than January 15th of the new year.
8. Special Circumstances: Dealers reconciling delinquent accounts for a previous year must submit surcharge information for each year on a separate form. As stated previously, you should never list a date span on a surcharge remittance form that covers more than one year.

SECTION A

1. BUSINESS NAME: Self-explanatory.
   
2. LICENSEE/SHERIFF NAME: Self-explanatory.
   
3. BUSINESS ADDRESS: Enter the licensee/sheriff/chief's address. If the address is an RD number, e.g., RD 1, Box 345, an actual street name is also required such as RD 1 (Old Jonestown Road), Box 345.
4. CITY: Self-explanatory.
5. STATE: Self-explanatory.
6. ZIP CODE: Self-explanatory.
7. BUSINESS TELEPHONE NO.: Self-explanatory.
8. FEDERAL FIREARMS LICENSE NO.: Enter the licensee’s Federal Firearms License number.
9. DEALER OR SHERIFF NUMBER (Dealer Number): Enter the licensee’s State Firearm ID (identification) number. Do not enter your Federal Firearms License number or the purchaser’s Driver’s License number. This area is for your State Firearm ID number only.
   
10. EMAIL ADDRESS: Self-explanatory.

SECTION B

For each category listed in this section, a total number shall be placed in the corresponding block.

For the amount due column, the licensee/sheriff/chief shall multiply the total by either the surcharge fee amount or PICS fee amount depending on the category, to obtain the amount due.

The total amount due category shall be obtained by adding up all of the amount due columns and placing that number in the total amount due block.

The licensee/sheriff/chief shall then prepare a check payable to "Pennsylvania State Police FSSF" and forward it to the address provided on the form within 14 days of every sale, transfer, or instantaneous records check conducted during the date span indicated on the form.

SECTION C

This section shall be utilized by the licensee/sheriff/chief to record approvals, denials, and the date they were obtained.

After each approval number, list the month and day of approval, e.g., 1/10, and total number of guns sold/transferred, e.g., if 3 taxable handguns were sold under this approval number, you would list the number "3" under column "THG".

For denials, list "D" or "Denied" under "Approval No./Denied", month and day under date, and nothing for the No. of Each sold/transferred.

If additional space is needed, the licensee/sheriff/chief shall utilize the Surcharge Remittance Continuation form SP4-134A.

SECTION D

The licensee/sheriff/chief shall read this section and sign and date it when finished. By signing the application, the licensee/sheriff/chief is certifying the information on the form is correct and that an instantaneous records check was performed on all firearms as defined in § 6111.2 transactions indicated.