HomeMy WebLinkAbout01-17-08 (2)
SP 4-131 (5-2006)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Pennsylvania Uniform Firearms Act, 18 RloC.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.S.A. 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. S 6109(1.1)(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
302 303 304 OTHER
INVOLUNTARY COMMITMENT 0 0 0
o ADJUDICATED INCOMPETENT lZJ
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT
COUNTY OF COMMITMENT CUMBERLAND
1 /17/8
INDIVIDUAL INFORMATION - INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT
LAST NAME KIRK FIRST CAROLYN MIDDLE H
JR., ETC. MAIDEN NAME ALIAS
DATE OF BIRTH /25 / 1926 SOCIAL SECURITY NUMBER 210-16-6935
SEX~ RACE W HEIGHT 5 ,4 WEIGHT 100 LBS. HAIR GREY EYES BLUE
ADDRESS GOLDEN LIVING CENTER - WEST SHORE - 770 POPLAR CHURCH ROAD CAMP HILL PA 17011
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)
Hospital/ Facility Providing Treatment / Address NIA
Please Print Name and Provide Sianature
...........................................................................................
NOTIFICATION BY (Please print name, address, area code, and telephone number of agency or county court.)
MH/MR Administrator/Review Officer N/A Telephone 7172406345
303-304 Commitment requires the Judge/Review Officer name authorizing the commitment, case number, & order date
Judge/Review Officer KEVIN A HESS, JUDGE
Date of Court Order 1
(17 18
Court Case Number 21-07-1121
4/., Date I I / '1 / d f?
........................................... ............~.....................~......~~.I
NOTIFICATION OF PHYSICIAN'S DETERMINATIO THAT NO SEVERE MENTAL DISABI~XISTS~,;'-\
The physician shall provide signed confirmation of the lack of s ere mental disability following the initial examinatiOlj ]f\der Sect~ 302(b..,. Of..tfr~.
Mental Health Procedures Act and pursuant to the Pennsylvania niform Firearms Act, Section 6111.1 (g)(3). Notice sha't;O:~nsmitfird by physici<l~
to the Pennsylvania State Police through the county Mental health and Mental Retardation Administrator or ental Health Rev~ficeG -
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Name - Physician (Please print.)
SIGNATURE OF NOTIFYING OFFIC IAL
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Signature - Physician
Date
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Original: Pennsylvania State Police
Copy: County Sheriff's Office (see web site: www.pasheriffs.org for current sheriff information)
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