HomeMy WebLinkAbout06-30-08 (2) P 4131(: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
Procedure's 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 Permsylvania 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(1.1)(2). The envelope should be marked "CONFIDENTIAL -ATTENTION FIREARMS."
Piace an "X" on either Involuntary Commitment and indicate 302, 303, 304, or Adjudicated Incompetent
PRINT CLEARLY oR TYPE sot 303 304 OTHER
INVOLUNTARY COMMITMENT ^ ^ ^ ^ ADJUDICATED INCOMPETENT ^/
DATE C)F COMMITMENT OR ADJUDICATED INCOMPETENT s ~ 19 ~ 2008
COUNTY OF COMMITMENT CUMBERLAND
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT
LAST NAME PIPER
JR., ETC. MAIDEN NAME
ALIAS
MIDDLE L
DATE OF BIRTH 6 / 26 / 1967 SOCIAL SECURITY NUMBER 176-58-6480
SEX ti1ale RACE WHITE HEIGHT 5 ' 0 WEIGHT 100 LBS. HAIR BROWN EYES BROWN
ADDRESS 22 SCHOOLHOUSE ROAD NEWVILLE PA 17241
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 Signature
Hospital /Facility Providing Treatment /Address
^^~~r~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
NOTIFICATION BY (Please print name, address, area code, and telephone number of agency or county court.)
MH/MR Administrator/Review Officer
Telephone 717 240 6345
303-304 Commitment requires the Judge/Review Officer name authorizing the commitment, case number, & order date
Judge/IReview Officer J Wesley Oler, Jr., Judge
Court Case Number 21-08-0546 ~ Date of Court Order 6 / 19 / 2008
SIGNATURE OF NOTIFYING OFFICIAL Date -~, / l(g / ~~
- .-;
NOTIFICATION OF PHYStCIAN's DETERMIN TION THAT NO SEVERE MENTAL DISABILITY' I~CISTS
The physician shall provide signed confirmation of the lack of severe mental disability following the initial examination udd,~r--~Secti6~302(b) of the'
Mental Health Procedures Act and pursuant to the Pennsylvania Uniform Firearms Act, Section 6111.1 (g)(3). Notice shal4 tfe~nsmitted by physician
to the Pennsylvania State Police through the county Mental health and Mental Retardation Administrator or ental Health:Revf~w-pfficer~
Name -Physician (Please print.) ? ~ , ~''
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Signature -Physician Date / / ~_
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FIRST RICHARD
Original: Pennsylvania State Police
Copy: County Sheriff's Office (see web site: www.pasheriffs.org for current sheriff information)