HomeMy WebLinkAbout12-15-08 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 involuntadly committed to a mental institution for inpatient care and treatment under Section 302, 303, or 304 of the Mental Health
Procedures aG of July 9, 1976 (P.L. 817, No. 143) to possess, use, manufacture, control, sell or transfer firearms. This would include adjutlication of
incapacity pursuant to 20 Pa.C.S.A. 5501. Pursuant to the Pennsylvania Mental Health Procedures AG, Section 109, notifcation 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 Gass mail to the Pennsylvania State Police, Attention: PICS Unit, 1800 Elmerton
Avenue, Harrisburg, PA 17170. A copy of this form must also be forwarded to the sheriff of the county in which this person
resides in accordance with 16 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 ^ ^ ^ ^ ADJUDICATED INCOMPETENT ^/
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT 12 / 12/2008
COUNTY OF COMMITMENT CUMBERLAND
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT
LAST NAME SIPS
JR., ETC. MAIDEN NAME
DATE OF BIRTH 8 / 5 / 1934
SEX M RACE CAUCASIAN HEIGHT 6 ' 0 WEIGHT 260 LBS
ADDRESS 700 WALNUT BOTTOM ROAD, 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 Signature
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 JUDGE EDWARD E GUIDO
Court Case Number 21-2008-1118
Date of Court Order 12 / 12 / 2008
SIGNATURE OF NOTIFYING OFFICIAL 7 v Date ~oZ / ~ ~ / a~j
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, pJ~'y~sician
to the Pennsylvania State Police through the county Mental health and Mental Retardation Administrator or ental Fleall~2e~yiAsy pfhder, _ JJ
Name -Physician (Please print.) lei ~(. ~ ~ ~~~~i~~~U~O
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Signature -Physician
Date / /
Original: Pennsylvania Stale Police
Copy: County Sheriff s Office (see web site: www.oasheriffs.ore for current sheriff information)
ALIAS
SOCIAL SECURITY NUMBER 168-26-3655
FIRST ROBERT
HAIR GREY EYES GLUE/GREEN
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