HomeMy WebLinkAbout12-09-11SP 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 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 include adjudication of
incapacity pursuant to 20 Pa.C.S.A. 5501. Pursuant to the Pennsylvania Mental Health Procedures Act, 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 class mail to the Pennsylvania State Police, Attention: PICS Unit, 1800 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. § 6109(1.1)(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 302 303 304 OTHER
INVOLUNTARY COMMITMENT ^ ^ ^ ^ ADJUDICATED INCOMPEIT ^/ ~ ,_
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT 12 ~ oz ~ 2011 ~ ~~~ .
COUNTY OF COMMITMENT CUMBERLAND ~ x ~
- ,~~
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATE-by~ICOMPETENT- --.
> ° - ;-,=
LAST NAME SITLINGER FIRST MILDRED MIDDL~ MARIE r ~ ;;.~ r
r=,
JR., ETC. MAIDEN NAME ROTHERMEL ALIAS
DATE OF BIRTH 10 / 08 / 1929 SOCIAL SECURITY NUMBER 174-24-5631
SEX F RACE WHITE HEIGHT 5 ' 2 WEIGHT 150 LBS HAIR SILVER EYES BLUE
ADDRESS 4905 EAST TRINDLE ROAD, MECHANICSBURG, PA 17055
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 Provide Signature
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, & order date
Judge/Review Officer M. L. EBERT JR
Court Case Number 21-11-0976 ate f Court Order 12 / 02 / 2011
SIGNATURE OF NOTIFYING OFFICIAL r ~ Date IZ / 9 / ~I
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 bey transmitted by physician
to the Pennsylvania State Police through the county Mental health and Mental Retardation Administrator or ental Health Revie~N Officer.
Name -Physician (Please print.)
Signature -Physician
Date / /
Original: Pennsylvania State Police
Copy: County Sheriff's Office (see web site: www.pasheriffs.ore for current sheriff information)