HomeMy WebLinkAbout11-05-08 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 file 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. § 8109(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 CUMBERLAND
ADJUDICATED INCOMPETENT ^/ -~
_ :_
11 ~ 4 ~ 2008 -
'r r ..
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED. tNCOMPENT
LAST PJAME CALAMAN FIRST MARLIN MIDDLfr_ ~'
-,
JR., El"C. MAIDEN NAME ALIAS ~-
DATE OF BIRTH 4 / 14 / 1928
SOCIAL SECURITY NUMBER 200-22-5009
SEX I~ RACE CAUCASIAN HEIGHT 6 ' 0 WEIGHT 150
ADDRESS 6 WESTMINSTER COURT, CARLISLE PA 17013
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 Sianature
NOTIFICATION BY (Please print name, address, area code, and telephone number of agency or county court.)
MH/MI~ 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
21-2008-0980
Date of Court Order 11 / 4 / 2008
SIGINATURE OF NOTIFYING OFFiCIAL~~~~~~~~~~ ~~~~~---.~~~~~~.~~ Date~~~~.~~~:~/ ~ 2.. ~.~,
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 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
HAIR BROWN EYES BLUE
Date / /
Original: Nennsylvania State Police
Copy: County Sheriff s Office (see web site: www.pasheriffs.ora for current sheriff information)