HomeMy WebLinkAbout06-30-08 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
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(1.1}(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 ^ ^ ^ ^
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT
COUNTY OF COMMITMENT U~`~">~'~~
SOCIAL SECURITY NUMBER
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT
LAST NAME ~C.-( FIRST ~ I ~ ~~- MIDDLE r V\
JR., ETC. MAIDEN NAME _
DATE(O~F BIRTH f~ / I ~ / ~~~~
SEX r RACE ' {~(C?CiS~~iEIGHT
ADDRESS rI~T r UX ~r1-~-
l ~l~zC~~r
ALIAS
_ WEIGHT HAIR ~_ EYE
_ _~.
.(l~ ~ ~~~-(I ~ ~ t; ~ -.
-~ ._
302 Commitment Requires Physician's Certification " -" ~,._~
c~
Physician Certifying Necessity of Involuntary Commitment
(Required in accordance with Section 6105(c)(4) of the Uniform Firearms Act) Please Print Name and Provide ~iiittatur~~
Hospital /Facility Providing Treatment /Address ~=~='i ~'=~
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NOTIFICATION BY (Please print name, address, area code, and telephone number of agency or county court.)
MH/MR AdministratorJReview Officer
303-304 Commitment re~q(uires the Judg~e/R
Judge/Review Officer~,~y~~ E~+~~r C~-~
~-v
Court Case Number o2 ~ - ~~~~ `
Telephone
Officer name authorizing the commitment, case num r, & order date
Court Order C~ ~P l~ I o~C)U
SIGNATURE OF NOTIFYING OFFICIAL ~~l-l,W[ ~~V~V 1 ~ l Date ~ /~0 / a~
....rr....^......^.^...rr .................^^.~.~......^r ...-.......rr..^^^^......^........~
NOTIFICATION of PHYSICIAN'S DETERMINATION THAT NO SEVER 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
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
ADJUDICATED INCOMPETENT ~I
Date ! /
Original: Pennsylvania State Police
Copy: County Sheriff's Office (see web site: www.pasheriffs.org for current sheriff information)