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SP 4-131 (5-2006)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Pennsylvania Uniform Firearms Act, 18 Pa. C.S 6105(c) (4) specifies that it shall be unlawful for any person adjudicated as an incompetent or who has been
involuntarily committed to a mental institution for inpatient care and treatment under Section 302, 303, or 304 of the Mental Health Procedures act of July 9, 1976
(P.L. 817, No. 143) to possess, use, manufacture, control, sell or transfer firearms This would include adjudication of incapacity pursuant to 20 Pa.C.SA 5501.
Pursuant to the Pennsylvania Mental Health Procedures Act, Section 109, notification shall be transmitted to the Pennsylvania State Police by the judge, mental
health review officer, or county mental health and mental retardation administrator within SEVEN days of the adjudication, commitment or treatment by first class
mail to the Pennsylvania State Police, Attention: PICS Unit, 1800 Elmerton Avenue, Harrisburg, PA 17110. A copy of this form must also be forwarded to
the sheriff of the county in which this person resides in accordance with 18 Pa.C.S. !i 6109(i.1) (2). The envelope should be marked "CONFIDENTIAL-
ATTENTION FIREARMS."
Place an "X" on either Involuntary Commitment and indicate 302,303,304, or Adjudicated Incompetent
PRINT CLEARLY OR TYPE
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302
303 304
OTHER
INVOLUNTARY COMMITMENT D D D
G
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT
COUNTY OF COMMITMENT Cumberland
INDIVIDUAL INFORMATION - INDIVIDUAL INVOLUNTARilY COMMITTED OR ADJUDICATED INCOMPETENT
LAST NAME Waller FIRST Reqinald MIDDLE
JR., ETC. N/A MAIDEN NAME N/A ALIAS N/A
DATE OF BIRTH 01/29/1940 SOCIAL SECURITY NUMBER 346-30-4098
SEX M...- RACE Black HEIGHT 7'1" WEIGHT 1331bs. HAIR qrev/dark brown EYES brown
ADDRESS 46 Erford Road. Camp Hill. PA 17011
D ADJUDICATED INCOMPETENT
04/23/07
302 Commitment Requires Physician's Certification
Physician Certifying Necessity of Involuntary Commitment
(Required in accordance with Section 61 05(c)(4) of the Uniform Firearms Act)
Please Print Name and Provide SiQnature
Hospital/Facility Providing Treatment / Address
NOTIFICATION BY (Please print name, address, area code, and telephone number of agency or county court.)
MH/MR Administrator/Review Officer
Telephone
303 and 304 Commitment requires the Judge's name authorizing the commitment, case number, & order date
Judge M.l. Ebert
Court Case Number
Date:rcourt Order ---M-/-11-/ 07
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~,\\ \... \.. Y Date ~/~/ () 7
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............................................................'III..................................... II.....
O.C.2007-214
SIGNATURE OF NOTIFYING OFFICIAL
NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABILITY EXISTS
The physician shall provide Signed confirmation of the lack of severe mental disability following the initial examination under Section 302(b) of the Mental Health
Procedures Act and pursuant to the Pennsylvania Uniform Firearms Act, Section 611.1 (g)(3). Notice shall be transmitted by physician to the Pennsylvania State
police through the county Mental health and Mental Retardation Administrator or ental Health Review Officer.
Name - Physician (Please print.)
Signature - Physician
Date _/_/
Original: Pennsylvania State Police Copy:
County Sheriffs Office (see web site: www.oasheriffs.org for current sheriff information)
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