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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 ,104 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. S 6109(i.1)(2). The envelope should be marked "CONFIDENTIAL - ATTENTION FIREA~MS."
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Place an "X" on either Involuntary Commitment and indicate 302, 303, 304, or Adjudicated I~etent =
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PRINT CLEARLY OR TYPE 302 303 304 OTHER~;~g ~
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INVOLUNTARY COMMITMENT D 0 D D ADJUDICATED INCOMPE~t}Zl
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DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT 4 / 16 /2008:-:-)~~ <2
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COUNTY OF COMMITMENT CUMBERLAND w
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARilY COMMITTED OR ADJUDICATED INCOMPETENT
lAST NAME Gardosik FIRST Elizabeth MIDDLE McHale
JR., ETC. MAIDEN NAME Kozlosky ALIAS
DATE OF BIRTH 8 /27 / 1926 SOCIAL SECURITY NUMBER 198-20-6088
SEX~ RACE C HEIGHT 5 -7 WEIGHT 150 HAIR GREY EYES Hazel
ADDRESS 4814 Virginia Road, Mechanicsburg, PA 17050
302 Commitment Requires Physician's Certification
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
NOTIFICATION BY (Please printrame,
...........................................................................................
MH/MR Administrator/Review Officer
telephone number of agency or county court.)
Telephone 717-240-6345
r name authorizing the commitment, case number, & order date
Court Case Number 21-08-0224
te of Court Order 4
/ 16 / 2008
SIGNATURE OF NOTIFYING OFFICIAL
Date '"( / i'F" / C>~
.................................
.....................................
NOTIFICATION OF PHYSICIAN'S DETERMI ~TION 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
rv1ental 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 rv1ental health and rv1ental 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 sheriffinfonnation)