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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. ~ 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 INCOMPETEN1'dll
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT
COUNlY OF COMMITMENT CUMBERLAND
3 / 5 / 2008
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INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARilY COMMITTED OR ADJUDICATED INCOMPETBt-Pf
LAST NAME NEELY
FIRST JANNETTE
MIDDLE L
['-..)
r'.........
JR., ETC. MAIDEN NAME LEONARD ALIAS
DATE OF BIRTH 8 /22 /1921 SOCIAL SECURllY NUMBER 204-03-0273
SEX ~ RACE WHITE HEIGHT 5 ,3 WEIGHT 135 HAIR GRAY
ADDRESS 59 N EAST STREET, CARLISLE PA 17013
302 Commitment Requires Physician's Certification
EYES GREEN
Physician Certifying Necessity of Involuntary Commitment
(Required in accordance with Section 6105(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.)
MH/MR 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
of Court Order 3
/5
/ 2008
Court Case Number 21-08-0032
SIGNATURE OF NOTIFYING OFFIC I~
Date 7. /1" / 0 11
......................................
....................................
NOTIFICATION OF PHYSICIAN'S DETERMINATION TH NO SEVE MENTAL DISABILITY EXISTS
The physician shall provide signed confirmation of the lack of severe mental disability 1I0wing the 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.org for current sheriff information)