HomeMy WebLinkAbout07-31-12 (2)SP 4-131 (3-2009)
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
in accordance with 18 Pa. C.S. 6111.1(f)(1)(i), judges of the courts of common pleas shall notify the Pennsylvania State Police (PSP) of the identity of
any individual who has been adjudicated as an incompetent or as a mental defective or who has been involuntarily committed to a mental institution
under the act of July 9. 1976 (P. L. 817, No. 143), known as the Mental Health Procedures Act, or who has been involuntarily treated as described in
section 6105(c)(4) (relating to persons not to possess, use, manufacture, control, sell or transfer firearms) or as described in 18 U.S.C. §922(8)(4)
(relating to unlawful acts) and its implementing Federal regulations. This notification shall be transmitted by the judge to the PSP within SEVEN days of
the adjudication, commitment, or treatment, at the address below.
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 PSP
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, 180D Elmerton Avenue, Harrisburg, PA
17110. A copy 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 INCOMPETENT ~O ,~.,
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DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT 07-30-2012
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INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATE~~
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LAST NAME FIRST BARBARA MID~E A
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JR., ETC. MAIDEN NAME MALASHESAI ALIAS ''~
DATE OF BIRTH 02/21/1942 SOCIAL SECURITY NUMBER 181-32-9086
(Optional, but will help prevent misidentification)
SEX F RACE CAU. HEIGHT 5 ' 4 WEIGHT 203 HAIR GREY/WHITE
ADDRESS GOLDEN LIVING CENTER 46 ERFORD RD. CAMP HILL PA 17011
EYES GREY
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/P.evie~r Officer name authorizing the commitment, case number, & order date
Judge/Review Officer CHRISTYLEE L PECK
Court Case Number 21-12-0759 Date of Court Order 7/30/2012
SIGNATURE OF NOTIFYING OFFICIAL - ~ ~~ate < Q
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 Mental Health Review Officer.
Name -Physician (Please print.)
Signature -Physician
Date
PRIVACY ACT NOTICE: Solicitation of this information is authorized under Title 18 Pa. C.S. §6111.1 and Tine 50 Pa. C.S. §7109. Disclosure of
your social security number is voluntary. Your social security number, if provided, may be used to verify your identity and prevent misidentification.
All information supplied, including your social security number, is confidential and not subject to public disclosure.
Original: Pennsylvania State Police
Copy: County Sheriff's Office (see web site: www.Dasheriffs.org for current sheriff information)