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SP 4-131(5-2006)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Pennsylvania Uniform Firearms Act, 18 Fa.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. ~ 6109(i.1)(2). The envelope should be marked "CONFIDENTIAL - ATTENTION FIREARM5."
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
D ADJUDICATED INCOMPETENT 0
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT
COUNTY OF COMMITMENT CUMBERLAND
1 / 23 / 2008
INDIVIDUAL INFORMATION - INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT
LAST NAME MAZER
JR., ETC.
FIRST MICHELE
MIDDLE SARAH
MAIDEN NAME FIESELER ALIAS
/24 /1980 SOCIAL SECURITY NUMBER 003-74-8615
DATE OF BIRTH 10
SEX ~ RACE ~ HEIGHT 5 ' 6 WEIGHT
ADDRESS 6460 BRANDY LANE MECHANICSBURG PA 17055
140
HAIR BROWN
EYES HAZEL
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
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
Telephone 717240634
303-304 Commitment requires the Judge/Review Officer name authorizing the commitment, case number, & order date
Judge/Review Officer M. L. EBERT JR., JUDGE
Court Case Number 21-07-1169
/ 23 / 2008
SIGNATURE OF NOTIFYING OFFIC IAL '\ Date ,-I, / 2 3 f~ Oi) e
........... . . ..... . . .... . ..... . . ............ ............ . ........... ~ ~..... ~...... ~:,~I
NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE ME TAL DISABILlp(tic~TS 3:: ... .
The physician shall provide signed confirmation of the lack of severe mental disability following the initial examinatioll ghdef Secti;;: 302(o)Of the
Mental Health Procedures Act and pursuant to the Pennsylvania Uniform Firearms Act, Section 6111.1 (g)(3). Notice shal!~ilnsm~ by physicii:ln
to the Pennsylvania State Police through the county Mental health and Mental Retardation Administrator or ental HealthRe~L~~'?fficer. u_
Name - Physician (Please print.)
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Signature - Physician
Date
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Original: Pennsylvania State Police
Copy: County Sheriff's Office (see web site: www.Dasheriffs.org: for current sheriff information)