HomeMy WebLinkAbout08-06-08 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."
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Place an "X" on either Involuntary Commitment and indicate 302, 303, 304, or Adjudicatep-m~mpeten
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PRINT CLEARLY; oR TYPE 302 303 304 OTHER ,_i' ~
INVOLUNTARY COMMITMENT ^ ^ ^ ^ ADJUDICATED INCOMP~Et ITT =
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DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT =
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COUNTY OF COMMITMENT l 'al (1~Y ](~,l(1(C~11~11 u't
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INDIVIDUAL I(N~FIO,,R~,M, fA/TION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT
LAST NAME JC,•I' IC~t~ FIRST MIDDLE J.
JR., ETC. -MAIDEN NAME ALIAS ~-7 ~~""
DATE OF BIRTH _3 / ~vD / (°/~'Q SOCIAL SECURITY NUMBER ~ LD ~ " / ~ - l~/
SEX ~ RACE ~ HEIGHT t~' l~" WEIGHT HAIR ~ ~l~I - EYES b ~~
ADDRESS o2~_f L!`~(.lA ~+- ~~ ,~,n~,r'~,4- l 7 /~ 7~
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)
Hospital /Facility Providing Treatment /Address
Please Print Name and Provide Signature
~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ q / ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ 1
NOTIFICATION 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 .
Court Case Number _ r~L ~ - ~C ~Vb ~ ~`]` / 7 ~ Date of Court Order ~ / ~ / c~~~~
SIGNATURE OF NOTIFYING OFFICIAL ~ ~ Date ~ l ~ I Z~o~ -
............... ^ ......................... ............................................... 1
NOTIFICATION OF PHYSICIAN'S DETERMINAT N THAT NO SEVERE MENTAL DISABILITY EXISTS
The physician shall provide signed confirmation of the lack 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 (Pleaase print.)
Signature -Physician
Date
Original: Pennsylvania State Police
Copy: County Sheriff's Office (see web site: www.nasheriffs.org for current sheriff information)