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SP4-131(5-2006)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Pennsylvania Uniform Firearms Act, 18 Al.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.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. ~ 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
302 303 304 OTHER
"
INVOLUNTARY COMMITMENT 0 0 0
o ADJUDICATED INCOMPET~t 0
. \ ,,"......'
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT
COUNTY OF COMMITMENT CUMBERLAND
3 / 7 / 2008
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INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARilY COMMITTED OR ADJUDICATED INCOMPETENT
r.J
LAST NAME MILLER FIRST MARTHA MIDDLE G C)
JR., ETC. MAIDEN NAME DUCKWORTH ALIAS
DATE OF BIRTH 2 /22 /1936 SOCIAL SECURITY NUMBER 254-48-3277
SEX ~ RACE WHITE HEIGHT 5 ' 4 WEIGHT 200 HAIR BLONDE
EYES GREEN
ADDRESS
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 Sianature
Hospital/ Facility Providing Treatment / Address
...........................................................................................
NOTIFICA TION BY (Please print name, address, area code, and telephone number of agency or county court.)
MHIMR Administrator/Review Officer
Telephone
303-304 Commitment requires the Judge/Review Officer name authorizing the commitment, case number, & order date
Judge/Review Officer EDGAR B BAYLEY
/7
/ 2008
Court Case Number 21-08-0110
SIGNATURE OF NOTIFYING OFFICIAL
Date
1 / 10/
(),
..........................................
.................................
NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE TAL DISABILITY EXISTS
The physician shall provide signed confirmation of the lack of severe mental disability following he initial examination under Section 302(b) of the
Mental Health Procedures Act and pursuant to the Pennsylvania Uniform Firearms Act, Section 6111.1 (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.ofl'>' for current sheriff information)