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HomeMy WebLinkAbout06-11-09 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 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(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 / / INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT LAST NAME Johnstone JR., ETC. MAIDEN NAME FIRST Georgia Rosman ALIAS DATE OF BIRTH 4 / 6 / 1937 SOCIAL SECURITY NUMBER 2g,i -Vii,-llnn SEX F RACE CaucasianHEIGHT 5 1 WEIGHT 1 ~O 1 he _ HAIR S~a~ EYES Hazel ADDRESS 522 Wilson Lane, Mechanicsburn PA 17055 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 Court Case Number Ot I ' ~ 1" Court Order l0 / ~© / 20C.~9 1 f ! ~ '~ SIGNATURE OF NOTIFYING OFFICIAL ~ Date ~ I ~d l ~ 9 NOTIFICATION OF PHYSICIAN'S DETERMIN ION 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 view Officer ea .o ,~ Name -Physician (Please print.) e... , t T ~- C iu a ~ ~ z 4~. u Signature -Physician Date Original: Pennsylvania State Police Copy: County Sheriff's Office (see web site: www.vasheriffs.ore for current sheriff information) MIDDLE D. ADJUDICATED INCOMPETENT = ~:` _ ~~ r'n ~ e,-~r:~ ~ .~,