HomeMy WebLinkAbout01-07-09 (3) P 4131(5-2006) ~ ~'~ " ~.~.~'~ ~"~
COMMONWEALTH OF PENNSYLVANIA - ~ r
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NOTIFICATION OF MENTAL HEALTH COMMITIVIL1~1'f " """
The Pennsylvania Uniform Firearms Act, 16 Pa.C.S. 6105(c)(4) specifies that it shall be unlawful for any perso_n44nnapd~~'yyu,di~~ciiatu~etd a~sl~anpint~~o el t or
who has been involuntarity committed to a mental institution for inpatient care and treatment under Section 304triIW,JyfR04 9r the pqe ~Ith
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, notifi fi s ~I,pe transmitted
to the Pennsylvania State Police by the judge, mental health review officer, or county mental health and mental retardation cccnn~~~ with) Imerton
days of the adjudication, commitment or treatment by frsl class mail to the Pennsylvania State Police, Attenti~t~'s DArson
Avenue, Harrisburg, PA 17110. A copy of this form must also be forwarded to the sheriff of the tF`
resides in accordance with 16 Pa.C.S. § 6109(1.1 )(2). The envelope should be marked "CONFIDENTIAL-
Place an "X" on either Involuntary Commitmem and indicate 302, 303, 304, or Adjudicated Incompetent
PRINT CLEARLY oR TYPE 302 303 3oa OTHER
INVOLUNTARY COMMITMENT ^ ^ ^ ^ ADJUDICATED INCOMPETENT ^/
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT 1 / 7 /2009
COUNTY OF COMMITMENT Cumberland
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT
LAST NAME Soller
JR., ETC. MAIDEN NAME
DATE OF BIRTH 1 / 14 /
SEX Male RACE Caucasian
ADDRESS 7 Saratoga Place, C
1937
FIRST Herbert
ALIAS
SOCIAL SECURITY NUMBER 204-28-4318
HEIGHT 5 ' 9 WEIGHT 1651bs HAIR Bald w/grey EYES Green
p Hill PA 17011
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
,.,,,..e ^a,.,~~,t ^ r.~d~h
Court Case Number 21-2008-0083
SIGNATURE OF NOTIFYING OFFICIAL
.......................................
Date of Court Order 1 / 7 / 2009
Date ~ / /
..........................................
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 i(9 i(I examination under Section 302(b) of the
Mental Health Procedures Act and pursuant to the Pennsylvania Uniform Firearms Act, Section 6111.1 3). Notice shall be transmitted by physician
to the Pennsylvania State Police through the county Mental health and Mental Retardation Administrator or ental Flealth Review Officer.
Name -Physician (Please print.)
Signature -Physician
Date / /
MIDDLE Isaac
Original: Pennsylvania Slate Police
Copy: County Sheriff s Office (see web site: www nasheriffs.ore for current sheriff information)