HomeMy WebLinkAbout04-09-10 P 4131(5-2006)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Pennsylvania Uniform Firoarms Aq, 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 troatment under Section 302, 303, or 304 of the Mental Health
Procedures aq of July 9, 1976 (P.L. 817, No. 143) to possess, use, manufacture, control, sell or transfer firearms. This would indude adjudication of
incapadry pursuant to 20 Pa.C.S.A. 5501. Pursuant to the Pennsylvania Mental Health Procedures Aq, 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, commttmeM w troatment by first Gass mail to the Pennsylvania State Police, Attention: PICS Unit, 1800 Elmerton
Avenue, Harrbburg, 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.3. § 8109(1.1x2). The envelope should be marked "CONFIDENTIAL -ATTENTION FlREgRMS"
Place an "X" on either Involuntary Commitmerd and indicate 302, 305, 304, or Adjudicated Incompetent o
e~ z~ ; •~,
PRINT CLEARLY oR TYPE 302 303 304 OTHER
cnxo s~~
INVOLUNTARY COMMITMENT `-" 7° ~'' '"
~ ^ ^ ^ ADJUDICATED INCOMPE I r
~ ~c ~ ~ f;
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT o4 / OB / 2010 O ..~ r7 C
COUNTY OF COMMITMENT Cumberland _
r '~
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETE~N3T l
LAST NAME Arms FIRST Sibyl
MIDDLE
JR., ETC. MAIDEN NAME ALIAS
DATE OF BIRTH 03 / O6 / 1937 SOCIAL SECURITY NUMBER 198-30-0565
SEX F RACE Cain
ADDRESS Golden
HEIGHT 5 ' 2 WEIGHT 164 HAIR White Hazel
EYES
Center West Shore 770
Church Road Camp Hiil PA 17011
302 Commitment Requires Physician's Certification
Physician Certifying NecassHy of Involuntary Commidnent
(Required in accordance with Section 6105(c)(4) of the Uniform Firearms Act)
Hospital /Facility Providing Treatment /Address
PleasePint Name arW provids1r~~a
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 Judge Albert H. Masland
Court Case Number 21-2010-0226
Date ofpCourt Order 04 / 06 / 2010
SIGNATURE OF NOTIFYING OFFICIAL ~ >/(~C Date y l g / ~ o CO
NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABILITY EXISTS
The physidan shall provide signed confirmation of the lade of severe mental disability following the initial examination under Section 302(b) of the
to the Pennsylvania SfatesPoliceh rough the county Mentalvhealth and NkntralRetardation Admi nstrotor(or(entaNFleaceHhsReview ~scemirtted by physidan
Name -Physician (Please print.)
Signature -Physician
Date __ / /~
Original: Pennsylvania State Police
Copy: County Sheriffs Office (see web site: www.o ch riff or for current sheriff information)