HomeMy WebLinkAbout10-29-08 (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
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 treat of th s formamust lalsohbe forty rded1t theeshelriff~of thetlcountyCn wh ch80his Iperson
Avenue, Harrisburg, PA 17110. A copy
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 Adjudicated Inco _ _ ~
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PRINT CLEARLY oR TYPE 302 303 304 OTHER _ r.~
INVOLUNTARY COMMITMENT ^ ^ ^ ^ ADJUDICATED INCOMPETENT ~' ~-
10 ~ 27 ~ zoos
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT -, ..
- c3
CUMBERLAND ~
COUNTY OF COMMITMENT
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT
LAST NAME MINAYA
JR., ETC. MAIDEN NAME
BIRTH 4 / 12 / 1949
FIRST JED
ALIAS
SOCIAL SECURITY NUMBER 183-40-0425
MIDDLE ~
DATE OF BROWN
SEX M RACE CAUCASIAN HEIGHT 5 ' 10 WEIGHT 253 HAIR BROWN EYES
ADDRESS 48 HONEYSUCKLE DRIVE, MECHANICSBURG PA 17050 AND MONTEFIORE HOSPITAL, PITTSBURGH PA 15213
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 print name, address, area code, and telephone number of agency or county court.)
H/MR Administrator/Review Officer
Telephone
M
303-304 Commitment requires the Judge/Review Officer name authorizing the commitment, case number, & order date
C~
Judge/Review Officer ~ - --
_ .. ~ ~ Date of Court Order ~~ l~ l l ol~~
Court Case Number
SIGNATURE OF NOTIFYING OFFICIAL Date ly l ~ 1 /i`u~
NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABILITY EXISTS
The physician shall provide signed confirmation of the lack of severe mental disability following the initi 3 e Notice shall be transm tted by(physiaan
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.)
Signature -Physician
Date / /
Original: Pennsylvania State Police
Copy: County Sheriff s Office (see web site: www nasheriffs.ora for current sheriff information)