HomeMy WebLinkAbout06-20-11 P 4131(5-2006)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Pennsylvania Unfforn Firearms Act, 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 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 indude adjudication of
incepaaly pursuant to 20 Pa.C.S.A. 5501. Pursuant to the Pennsylvania Mental Heakh Procedures Act, Section 109, notficefion 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 dass 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 sheriN of the county In which this parson
resides in accordance with 18 Pa.C.ti. g 8109(1.1x2). The envelope should ba marked "CONFIDENTIAL - ATTr:NirON FlREARAAS."
Place an "X" on either Involuntary Commitment and Indicate 302, 303, 304, or Adjudicated Incompetent
PRINT CLEARLY oft TYPE 302 303 304 OTHER
INVOLUNTARY COMMITMENT ^ ^ ^ ^ ADJUDICATED INCOMPETENT O
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT 08/ 17/2011
COUNTY OF COMMITMENT CUMBERLAND
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT
LAST NAME STERN FIRST ANDREW MIDDLE MICHAEL
JR., ETC. MAIDEN NAME ALIAS
DATE OF 81RTH 11 / 08 / 1987 SOCIAL SECURITY NUMBER 216-19-4126
SEX MALE RACE CAUCASIAN HEIGHT 5 ' 11 WEIGHT 235 HAIR BROWN EYES BROWN
ADDRESS ~ MT ROCK ROAD, CARLISLE PA 17015
302 Commitment Requires Physician's Certification ~~ .~`'
Physician Certifying NeceaaHy of Involuntary Commitment r`a ~-
(Required in accordance with Section 6105(c)(4) of the Uniform Firearms Act) Please PrIM Name and ~ ~ t.
Hospital /Facility Providing Treatment /Address ~ ~~ ~ ~~~~'
^^^^^^^^^^^^^^^^^..^^^.^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^.^^^^^^.~#~ ^i^^r~^^^irtlk~
NOTIFICATION BY (Please print name, address, area code, and telephone number of agena~or county tirt.)
MHRu1R Administrator/Review Officer Telephone ~'
303-304 Commitment requires the JtxJge/Review Olfioer name authorizing the commitment, case number, & order date
Judge/Review Officer ALBERT H. MASLAND, JUDGE
Court Case Number 21-2011-0514 Date of Court Order O6 / 17 / 2011
SIGNATURE OF NOTIFYING OFFICb~I~/~ ~~ /~~ Date ~ I `~ / -~ //
NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABILITY EXISTS
The physidan shall provide signed confirmation of the lads of severe merrtal disability following the inklal examination under Section 302(b) of the
Mental Health Procedures Ad and pursuant to the Pennsylvania Uniforn Firearms Act, Section 6111.1 (g)(3). Notice shall be transmitted by physician
to the Pennsylvania State Police through the county Mental health and AAental 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.oasheriffs.ore for current sheriff information)