HomeMy WebLinkAbout03-24-11 P 4131(5-2006)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Pennsylvania Uniform Firearms Act, 18 Pa.C.S. 6105(c)(4) speGfies 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, 1876 (P.L. 817, No. 143) to possess, use, manufacture, control, sell or transfer firearms. This would indude adjudiptbn of
incapacity pursuant to 20 Pa.C.S.A. 5501. Pursuant to the Pennsylvania Mental Health Procedures Ack 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 Gass mail to the Pennsylvania State Police, Attention: PICS Unit, 1600 Elmerton
Avenue, Harrisburg, 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.S. § 8109(i.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 30a OTHER
INVOLUNTARY COMMITMENT ^ ^ ^ ^ ADJUDICATED INCOMPETENT ^/
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT 03~23~2011
COUNTY OF COMMITMENT Cumberland
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT
LAST NAME Palmer
JR., ETC. n/a MAIDEN NAME n/a
FIRST Brittany MIDDLE Niwle
ALIAS n/a
DATE OF BIRTH 05 / 27 / 1988 SOCIAL SECURITY NUMBER 210-68-2789
SEX F RACE C HEIGHT 5 ' 0 WEIGHT 150 HAIR Sandy Broyrn EYES ~"~~ue
ADDRESS 1089 West Trindle Road, Mechanicsburg, PA 17055 ~Q --
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
tv
r
.,r ~ `,s
..................^.....^.........^..^.........^...^^.......^.^. ^......^^^.^. ^..+ji. ^...^^.~
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, 8 order date
Judge/Review Officer Edward E. Guido, Judge, Cumberland County Court of Common Pleas
Court Case Number Orphans' Court 21-11-0157
Date of Court Order 03 / 23 / 2011
SIGNATURE OF NOTIFYING OFFICIAL `~"'~ Date .~ /.s3 ///
NOTIFICATION OF PHYSICIAN'S DETERMINATION 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 Review Officer.
Name -Physician (Please print.)
Signature -Physician
Date / /
Original: Pennsylvania State Police
Copy: County Sheriff's Office (see web site: www.nasheriffs.org for current sheriff information)