Form DESPP-790-C "Verification or Change of Registration Information" - Connecticut

What Is Form DESPP-790-C?

This is a legal form that was released by the Connecticut Department of Emergency Services and Public Protection - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 28, 2014;
  • The latest edition provided by the Connecticut Department of Emergency Services and Public Protection;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DESPP-790-C by clicking the link below or browse more documents and templates provided by the Connecticut Department of Emergency Services and Public Protection.

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Download Form DESPP-790-C "Verification or Change of Registration Information" - Connecticut

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STATE OF CONNECTICUT
DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION
DIVISION OF STATE POLICE
Deadly Weapon Offender Registry Unit
Verification or Change of Registration Information
1. In accordance with C.G.S. § 54-280, et seq., any registered deadly weapon offender shall, without undue delay, notify the
Commissioner of the Department of Emergency Services and Public Protection (DESPP) of any changes in registration
information by completing this form and mailing it to DESPP, Deadly Weapon Offender Registry Unit, 1111 Country Club Road,
Middletown, CT. 06457-2389 or by calling (860) 685-8465. Any person subject to registration as a deadly weapon offender who
violates any provisions of C.G.S § 54-280a(a) or C.G.S § 54-280a(b) shall be guilty of a class D felony. Any person who is
subject to registration as a deadly weapon offender who fails to notify the DESPP Commissioner of a change of name or
address not later than five (5) business days after such change of name or address shall be guilty of a class D felony.
2. This form shall be used when a registrant is reporting:
a. An annual verification of registration information;
b. A name change and/or address change;
c. A name change through the Probate or Superior Court, complete Part VIII prior to filing the court application;
d. An employment, vocation, or student status at a trade or professional institution or institution of higher learning in
Connecticut; or
e. Any electronic mail address or other similar Internet communication address established, changed or used.
Part I. Registrant’s Information
Registrant’s Full Name:
DOB:
Last
First
M.I.
Month
Day
Year
Current Address:
Number
Street
City/Town
State
Zip Code
Apt./Condo Unit Number
Part II. Method of Positive Identification
Motor Vehicle Operator’s License:
State & Number: _____________________________
State-Issued Identification Card:
State & Number: _____________________________
Other, Explain:
Part III. Registration Anniversary Date
Note: This date can be located in COLLECT on the File 37 message.
Registration Anniversary Date: ____________________.
(mm/dd/yyyy)
.
Part IV. Name and/or Address Change
New Address:
Number
Street
City/Town
State
Zip Code
Apt./Condo Unit Number
This change of address becomes effective on ____________________.
(mm/dd/yyyy)
New Name:
Effective Date:
Last
First
Middle Name
Reason for Change:
Part V. Employment, Vocation, or Student Status
Out of State
In-State
Both Out of State and In-State
Name of Business and Full Address of Employment or Vocation:
(Number, Street, City/Town, State, Zip Code, Suite/Unit Number)
Name and Address of Trade or Professional Institution or Institution of Higher Learning:
(Number, Street, City/Town, State, Zip Code)
Part VI. Electronic Mail Address or Similar Internet Communication Address
Electronic Mail Address:
Other Internet Communication Address:
Page 1 of 2
DESPP-790-C (Rev. 10/28/14)
An Affirmative Action/Equal Employment Opportunity Employer
STATE OF CONNECTICUT
DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION
DIVISION OF STATE POLICE
Deadly Weapon Offender Registry Unit
Verification or Change of Registration Information
1. In accordance with C.G.S. § 54-280, et seq., any registered deadly weapon offender shall, without undue delay, notify the
Commissioner of the Department of Emergency Services and Public Protection (DESPP) of any changes in registration
information by completing this form and mailing it to DESPP, Deadly Weapon Offender Registry Unit, 1111 Country Club Road,
Middletown, CT. 06457-2389 or by calling (860) 685-8465. Any person subject to registration as a deadly weapon offender who
violates any provisions of C.G.S § 54-280a(a) or C.G.S § 54-280a(b) shall be guilty of a class D felony. Any person who is
subject to registration as a deadly weapon offender who fails to notify the DESPP Commissioner of a change of name or
address not later than five (5) business days after such change of name or address shall be guilty of a class D felony.
2. This form shall be used when a registrant is reporting:
a. An annual verification of registration information;
b. A name change and/or address change;
c. A name change through the Probate or Superior Court, complete Part VIII prior to filing the court application;
d. An employment, vocation, or student status at a trade or professional institution or institution of higher learning in
Connecticut; or
e. Any electronic mail address or other similar Internet communication address established, changed or used.
Part I. Registrant’s Information
Registrant’s Full Name:
DOB:
Last
First
M.I.
Month
Day
Year
Current Address:
Number
Street
City/Town
State
Zip Code
Apt./Condo Unit Number
Part II. Method of Positive Identification
Motor Vehicle Operator’s License:
State & Number: _____________________________
State-Issued Identification Card:
State & Number: _____________________________
Other, Explain:
Part III. Registration Anniversary Date
Note: This date can be located in COLLECT on the File 37 message.
Registration Anniversary Date: ____________________.
(mm/dd/yyyy)
.
Part IV. Name and/or Address Change
New Address:
Number
Street
City/Town
State
Zip Code
Apt./Condo Unit Number
This change of address becomes effective on ____________________.
(mm/dd/yyyy)
New Name:
Effective Date:
Last
First
Middle Name
Reason for Change:
Part V. Employment, Vocation, or Student Status
Out of State
In-State
Both Out of State and In-State
Name of Business and Full Address of Employment or Vocation:
(Number, Street, City/Town, State, Zip Code, Suite/Unit Number)
Name and Address of Trade or Professional Institution or Institution of Higher Learning:
(Number, Street, City/Town, State, Zip Code)
Part VI. Electronic Mail Address or Similar Internet Communication Address
Electronic Mail Address:
Other Internet Communication Address:
Page 1 of 2
DESPP-790-C (Rev. 10/28/14)
An Affirmative Action/Equal Employment Opportunity Employer
STATE OF CONNECTICUT
DEPARTMENT OF EMERGENCY SERVICES AND PUBLIC PROTECTION
DIVISION OF STATE POLICE
Part VII. Good Cause Shown Deferment
Note: This option is intended for use in exceptional circumstances only.
Date deferred to: ____________________.
(mm/dd/yyyy)
Description of circumstances validating deferment:
Part VIII. Change of Name Only Prior to Probate or Superior Court Application
Registrant’s Full Name:
DOB:
Last
First
Middle Name
Month
Day
Year
I am seeking to change my name to:
Last Name:
First Name:
Middle Name:
I am seeking to change my name for the following reason:
As a person who has been convicted, or who has been found not guilty by reason of mental disease or defect, of an offense committed with
a deadly weapon within the State of Connecticut, I am notifying the Commissioner of the Department of Emergency Services and Public
Protection (DESPP) of my intention to apply for a change of my name through a Probate Court or a Superior Court under the provisions of
C.G.S. § 52-11 and C.G.S. §54-280 et seq.
I understand that prior to filing such application with the Probate or Superior Court, I must notify the DESPP Commissioner on this form that
I intend to file an application for a change of name and indicate the change of name sought.
I hereby state that such change of name is not being sought for the purpose of avoiding the legal consequences of a criminal conviction,
including, but not limited to, a criminal conviction that requires me to register as an offender committing a crime with a deadly weapon.
I understand as a person subject to registration as a deadly weapon offender, if I violate any provisions of C.G.S §54-280a(a) or C.G.S §
54-280a(b), I shall be guilty of a class D felony.
I understand that as a person who is subject to registration as a deadly weapon offender if I fail to notify the DESPP Commissioner of a
change of name or address not later than five (5) business days after such change of name or address, I shall be guilty of a class D felony.
I understand that any false statement herein, which I do not believe to be true and which is intended to mislead a public servant in the
performance of his or her official function, is punishable by law (See C.G.S. § 53a-157b).
Registrant :
Date signed by registrant:
__________________
_____________________________________________________________________________
mm/dd/yyyy
Signature of Registrant (Signed in presence of Notary/Trooper/Police Officer)
Notary/Trooper/Police Officer:
Subscribed and sworn to before
me this
_____________________________________________________________________________
____ day of __________ 20___
Signature
Print Name
Date Commission Expires
Received by DESPP, Deadly Weapon Offender Registry Unit:
Date received at DESPP/DWOR Unit
_______________________
_____________________________________________________________________________
mm/dd/yyyy
Signature DESPP Registry Official
Print Name
Title
Distribution: 1) Original to DESPP DWOR Unit-Middletown
2) Copy to registrant
3) Court, for change of name only
Page 2 of 2
DESPP-790-C (Rev. 10/28/14)
An Affirmative Action/Equal Employment Opportunity Employer
Page of 2