HomeMy WebLinkAbout09-02-08 P4-131(5-2006) COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL IHEALTHuCOnMMITMENT as an incompetent or
The Pennsylvania Uniform Firearms Act, 18 Pa.C.S. 6105(c)(4) specifies
who has been involuntarily committed to a mentaYon ossess,fusen maa'nufacturea controlt sell or t ansfee fi ea mOs. Th s would include adjudicationltof
Procedures act of July 9, 1976 (P.L. 817, No. 143) p
incapacity pursuant to 20 Pa.C.S.A. 5501. Pu mental heath review) officernortcountylmenta health and men aloretardationlf administratobw'dhin SEVEN
Attention: PICS Unit, 1800 Elme on
to the Pennsylvania State Police by the judge,
days of the adjudication, commitment or treat of this formamust lalsohbe forwarded't theeshelr ff~of the county in which this person
Avenue, Harrisburg, PA 17110. A copy The envelope should be marked "CONFIDENTIAL -ATTENTION FIREARMS"
resides in accordance with 18 Pa.C.S. § 8109(1.1)(2).
Place an "X" on either Involuntary Commitment and indicate 302, 303, 304, or Adjudicated Incompetent
PRINT CLEARLY oR TY_ 302 303 304 OTHER
VOLUNTARY COMMITMENT ^ ^ ^ ^ ADJUDICATED INCOMPETENT ~
IN
8 ~14~2008
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT
COUNTY OF COMMITMENT Cumberland
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICDD E I CCOMPETENT
FIRST ALAN M
LAST NAME EPLER
ALIAS
JR., ETC. ~-MAIDEN NAME
16 1977 170-58-7477
DATE OF BIRTH 8 / / SOCIAL SECURITY NUMBER Brown
HAIR Brown EYES
RACE Caucasian HEIGHT 72~-- SIGHT 153
SEX M
ADDRESS 13 Colgate Drive, Camp Hill, PA 17011
302 Commitment Requires Physician's Certification
Physician Certitying 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
NOTIFICATION BY (Please print name, address, area code, and telephone number of agency or county court.)
Telephone
MH/MR Administrator/Review Officer
303-304 Commitment requites the Judge/Revue Officer~name~~ ring the commitment, case number, & order date
Judge/Review Officer
Date of Court Order ~ ~ ~~ / ~~
_ ~ -
CourtCaseNumber ~/ ~Z./ ~
Date
SIGNATURE OF NOTIFYING OFFICIAL
......................................... . ... .......................................
NOTIFICATION OF Plied confl rmati D oTERMIcNoA sIONe menta dOabiEy/followiMg NeALaDeSA Bnation uEndeSSection 302(b) of the
The physician shall provide sign 3 Notice shall be transmitted by physician
Mental Health Procedures Act and pursuant to the Pennsylvania Uniform Firearms Act, Section 6111.1 (g)( )•
to the Pennsylvania State Police through the county Mental health and Mental Retardation Administrator or ental Health Review Officer.
Name -Physician (Please print.)
Date ! /
Signature -Physician
Original: Pennsylvania State Police
Copy: County Sheriff's Office (see web site: www nasheriffs.ore for current sheriff information)