HomeMy WebLinkAbout09-22-09
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Pennsylvania Uniform Firearms Ad, 18 Pa.C.S. 6105(c)(4) spedfies 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
incapadty pursuant to 20 Pa.C.SA. 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 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. § 6109(i.1)(2). The envelope should be marked "CONFIDENTIAL -ATTENTION FIREAFtIIAS."
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 9 ~~~~ D9 '~ `" -'' ` `µT°~
c,; . .:~
COUNTY OF COMMITMENT ;~-- ~" '-'
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INO~IpENTyy„ ~-;~', '' z
NAME Barron FIRST Doris MIDDLE ~~-n ~ r=~-= ;--~
LAST . --
-.~ ,. ,
Clawson N/A ~~ `.~~: ,~~',
JR., ETC. MAIDEN NAME ALIAS -- ~~~ ,
DATE OF BIRTH 0.5 / OA / 1 ~2~ SOCIAL SECURITY NUMBER 163-~4-4391
SEX F RACE CaucasiorHEIGHT 5 1 WEIGHT 189 HAIR ~t,,~p'ES hl~P:_
ADDRESS 416 E. Green Street, Shiremanstown. Pa 17011
302 Commitment Requires Physician's Certification
Physician Certifying Necessity of Involuntary Commitment N/A
(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.)
MHMIR 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 o2~ - Q~ _Q ~~~ gate of Court Order ~ l ~7 / ~0~9
SIGNATURE OF NOTIFYING OFFICIAL ~~ ~ \ Date ~ /~/ Id4oo~7
NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABILITY EXISTS
The physician shall provide signed confirmation of the lads 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
Date / /
Original: Pennsylvania State Police
Copy: County Sheriff s Office (see web site: www.pasheriffs.org for current sheriff information)