HomeMy WebLinkAbout10-07-10 (2) 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 adjudicaped as an incompetent or
who has been involuntarily committed to a mental institution for inpatient care and treatment under Section 302, 303,'.. or 1304 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 inGude adjudication of
incapaaty pursuant to 20 Pa.C.S.A. 5501. Pursuant to the Pennsylvania Mental Health Procedures Act, Section 109, notifidafion shall be transmitted
to the Pennsylvania State Police by the judge, mental health review officer, or county mental health and mental retardation ajdministretor within SEVEN
days of the adjudipGon, commitment or treatment by first class mail to the Pennsylvania State Police, Attention: PIICS Unit, 1800 Elmerton
Avenue, Harrisburg, PA 17110. A copy of this form must also be forwarded to the sheriff of the cou'ntyj In which this person
resides in accordance with 18 Pa.C.S. § 8109(1.1)(2). The envelope should be marked "CONFIDENTIAL - ATtE N FIREARMS."
Place an "X" on either Involuntary Commitment and indicate 302, 303, 304, or Adludtcated Inc~oknpetent
PRINT CLEARLY OR TYPE sot 303 s04 OTHER
INVOLUNTARY COMMITMENT ^ ^ ^ ^ ADJUDICATED INCOMPEIT~WT ^/
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT ~ ~0
COUNTY OF COMMITMENT CUMBERLAND
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT
LAST NAME HOCKENSMITH FIRST DUSTIN
MIDDLE ~'~ SHAWN
JR., ETC. MAIDEN NAME ALIAS ~
DATE OF BIRTH 04 / 26 / 1982 SOCIAL SECURITY NUMBER 173'64-0688
~~ 170 BROWN ~, HAZEL
SEX M RACE W HEIGHT 6 ' 0 WEIGHT HAIR ~^ EYES
ADDRESS
3166 RITNER HIGHWAY NEWVILLE PA
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
NOTIFICATION BY (Please print name, address, area code, and telephone number of agency',
MH/MR Administrator/Review Officer
Telephone
303-304 Commitment requires the Judge/Review Officer name authorizing the commitment, case
JudgelReview Officer EDWARD E GUIDO, JUDGE
Court Case Number 21-10-0877
Date of Court Order
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SIGNATURE OF NOTIFYING OFFICIAL
NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABILI~fY ~(ISTS
The physiaan shall provide signed confirmation of the lack of severe mental disability following the initial examinati!pn rider Section 302(b) of the
Mental Health Procedures Act and pursuant to the Pennsylvania Un'rform Firearms Aet, Section 6111.1 (gx3). Notice $hal de transmitted by physician
to the Pennsylvania State Police through the county Mental health and Mental Retardation Administrator or ental Health) Re i~w Officer.
Name -Physician (Please print.)
Signature -Physician
Date / /
Original: Pennsylvania State Police
Copy: County Sheriff's Office (see web site: www.uasheriffs.org for current sheriff information)