HomeMy WebLinkAbout08-30-12COMMONWEALTH 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 involuntadly 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 Vansfer 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 he transmitted to the PSP
by the judge, mental health review officer, or county mental health and mental retardation adminisVator 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 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{I.1)(2). The envelope should be marlred "CONFIDENTIAL -ATTENTION FIREARMS:'
Place an "X" in type of Involuntary Commitment (302, 303, 304), Adjudicated Incapacitated, etc. Please type or print clearly.
INVOLUNTARY COMMITMENT 302 303 304 Q ADJUDICATED INCAPACITATEDI INCOMPETENT
^ ^ ^ ^ OTHER
DATE OF COMMITMENT OR ADJUDICATED INCAPACITATED, ETC. August 29, 2012
COUNTY OF COMMITMENT OR ADJUDICATION Cumberland
INDIVIDUAL INFORMATION - iNDIViDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCAPACITATED, ETC.
LAST NAME Napoli
FIRST Sarah
MIDDLE Kate
JR., ETC. MAIDEN NAME ALIAS Katie
DATE OF BIRTH 08/30/1994 SSN 603-82-0426 SEX Female RACE White
(Optional, but will help prevent misidentificaton)
HEIGHT 5'9: WEIGHT 310 HAIR Brown EYES Blue .a
ADDRESS 135 Simmons Road, Mechanicsburg PA 17055 ~r-, ry _,_,
Name of Physician Certifying Necessity of Involuntary Commitment
Hospital/Facility Providing TreatmentfAddress
^^^^^^^^^^^^^^^^^^ a ^^^^^^^^^^^^^^^^^^^^ u^^^^^^^^^^^^^^^^^J^^^^^^^^^^^^~'^^~
NOTIFICATION BY (Please print name, address, area code, and telephone number of agency or county cot) ~
MHlMR AdministratoriReview Officer Telephone 717-240-6345
Address
303-304 Commitments require the Judge/Review Officer name authorizing the commitment, case number, & order date
Name of Judge/Review Officer Judge Albert H. Masland
{Print Name)
Court Case Number 21-2012-0792 Date of Court Order August 29, 2012
SIGNATURE OF NOTIFYWG OFF{C Date F ~ Z
^^^^^^^^^^^^^^.^^^.^.^^^^^^^i u^^^^^^^^^^^^^^^^^^^^^. a^^^^^^^^^^.^^^^^^^ ^^^ ^^r^^^^^ru
NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABILITY EXISTS
The physician shall provide signed confirmation of the lade 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 Ad, 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 of Physician (Print Name)
Signature of Physician Date / /
PRIVACY ACT NOTICE: Solicitation of this Information is authorized under Title 18 Pa.C.S. §6111.1, and Title 50 P.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 sub%ect to public disclosure,
AOPC 1285 REV. 10/26/2009 /PSP No. SP4-131 (9-2009)
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