HomeMy WebLinkAbout08-05-10 P 4131(5-2006)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Pennsylvania Un'rfortn Firearms Ad, 18 Pa.C.S. 6105(c)(4) spedfies that tt shall lie unlawful for any person adjudicated as an incompetent or
who has been involuMariy committed to a mental institution for inpatient care and treatment under Section 302, 303, or 304 of the Mental Health
Procedures ad of July 9, 1878 (P.L. 817, No. 143) to possess, use, manufacture, control, sell or transfer firearms. This would indude adjudication of
incepadty pursuant to 20 Pa.C.S.A. 5501. Pursuant to the Pennsylvania Mental Health Procedures Act, Section 109, ratification shall Ue frensmiried
to the Pennsylvania State Police by the judge, mental health review officer, or county mental health end mental retardation administrator within SEVEN
days of the adjudication, commitment or treatment by first dass mail to the Pennsylvanla State Police, Attention: PICS Unit, 1800 Elmerton
Avenw, Harclaburg, PA 17110. A Dopy 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. § 8108(f.1x2). The envelope should be marked "CONFIDENTIAL -ATTENTION FIREARMS."
Plaes 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 oe ~ 02 ~ 2010
COUNTY OF COMMITMENT Cumberland
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT
LAST NAME Sharpe FIRST Alisha
JR., ETC. MAIDEN NAME
DATE OF BIRTH 03 / OS / 1991
ALIAS
MIDDLE Everie
SOCIAL SECURITY NUMBER 052-80-1239
SEX F RACE ~ HEIGHT 5 ' 4 WEIGHT
ADDRESS 836 Franklin Street, Carlisle PA 17013
302 Commitment Requires Physician's Certification
Physiclan CertNying Necessity of Involuntary Commitment
(Required in accordance wtth Section 8105(c)(4) of the Uniform Firearms Ad)
Hospital /Facility Providing Treatment! Address
105 HAIR Black EYES Brown
Please Print Name and Provide Sianature
..^....rrrrr.rrrr^rrrrr.^^^.^^^.^^r.rr~r.r.rr^r.rr^^^^.^^^^.^^rrrrrrrrr.rrrrr,rr~rr^^^^.^^.^^.^^rrr,r,•^urrrrrrrrrtrrrr^^^^.r
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 Oifcer name authorizing the commitment, case number, & order date
Judge/Review Officer
Court Case Number
Judge Edward E. Guido
21-10-0653
Date of Court Order 08 / 02 ! 2010
SIGNATURE OF NOTIFYING OFFICIAL ~ Date ~ I SI ~0
.....rr ..............r......rr.^.rrrr^............rr.......rrrr.rr.^..........^.rrr,r,.^.arr.^.~rrrr^.^,
NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABILITYS o 5
The physidan shall provide signed confirmation of the lack of severe mental disability following the inttial examination ection ) of ~
Mental Health Procedures Act and pursuant to the Pennsyvania Uniform Firearms Act, Section 6111.1 (g)(3). Notice shall edhysicR,
to the Pennsylvania State Police through the county Mental health and Mental Retardation Administrator or ental Hsatth Revi~~ , ~ ~ ~
Name -Physician (Please print.) 1,.-
Signature -Physician Date / ! ~J~ ~ ~ -=
--t ..
W ~ 7.
Original: Pennsylvania State Police ~
Copy: County Sheriff's Office (see web site: www.oasheriffs.ore for current sheriff information)