HomeMy WebLinkAbout11-21-12COMMONWEALTH 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 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 oT 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 adriinistrator within SEVEN days of the adjudication,
commitment or treatment by first class mail to the Pennsylvania State Police, Attention: PICS Unlt, 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(1.1)(2). The envelope should be marked "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 ~ ADJUDICATED INCAPACITATED! INCOMPETENT
^ ^ ^ ^ OTHER
DATE OF COMMITMENT OR ADJUDICATED INCAPACITATED, ETC. 11/15/2012
COUNTY OF COMMITMENT OR ADJUDICATION Cumberland
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCAPACITATED, ETC.
LAST NAME Kn
FIRST Kathleen
MIDDLE M
JR., ETC. MAIDEN NAME Mann ALIAS
DATE OF BIRTH 02/11/1933 SSN 161-26-8712 SEX Female RACE Caucasian
0 tional, but will het
( p p prevent misidentification)
C7 ~
_. -
HEIGHT 5,~„ WEIGHT 1221bs HAIR Dark Brown EYES _
Brown ~~~ ~~
_~?^
ADDRESS 23 W. Lawn Circle, Wormleysburg, Pa 11 _, _ ~ --- r;
Name of Physician Certifying Necessity of Involuntary Commitment ~ ' ~__-
(Print Narj1) ;;
Hospital/Facility Providing TreatmenVAddress - - p -_- '~r=;
D w ~~ p
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.
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NOTIFICATION BY (Please print name, address, area code, and telephone number of agency or county court.)
MH/MR Administrator/Review Officer
Address
Telephone 717-240-6345
303-304 Commitments require the Judge/Review Officer name authorizing the commitment, case number, 8 order date.
Name of Judge/Review Officer Edward E. Guido, Judge
(Print Name) _
Court Case Number 21-2012-0946 Date of Court Order 11/15/2012
SIGNATURE OF NOTIFYING OFFICIAL Date ~ ~~
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 of Physician (Print Name)
Signature of Physician
Date
PRIVACY ACT NOTICE: Solicitation of this information is authorized under Title i8 Pa.C. S. §6111.1, and Title 50 P.S. § 7109. Disclosure of your
social security number rs voluntary. Your social security nurnber, i/ 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.
AOPC 1285 REV. 10!26/2009 /PSP No. SP4-131 (9-2009)