HomeMy WebLinkAbout01-18-13COMMONWEALTH 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 art of July 9, 1y76 (P.L. 817, No. 143), known as the Mental Health Procedures Act, or who has 'peen 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(9)(4)
(relating to unlawtul acts) and its implementing Federal regulations. This notification shall be transmitted by the judge to fhe PSP within SEVEN days of
the adjudication, commitment, or treatment, a[ the address below.
The Pennsylvania Uniform Firearms Act, 18 Pa.C.S. 6105(c)(4) specifies that'd 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
ty the judge, mental health review officer, or county mental health and mental retardation administrator within SEVEN days of the adjudication,
coirnnitment 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(1.1)(2). The envelope should be marked "CONFIDENTIAL -ATTENTION FIREARMS"
Place an "X" in type of Involuntary Commitment (302, 303, 3041, Adjudicated Incapacitated, etc. Please type or print clearly
INVOLUNTARY COMMITMENT 302 303 304 ~ ADJUDICATED INCAPACITATED! INCOMPETENT
^ ^ ^ ^ OTHER _
DATE OF COMMITMENT OR ADJUDICATED INCAPACITATED, ETC. January 16, 2013
COUNTY OF COMMITMENT OR ADJUDICATION Cumberland
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCAPACITATED, ETC.
LAST NAME Goddard
FIRST Betty MIDDLE G
JR., ETC. MAIDEN NAME Johnson ALIAS
DATE OF BIRTH 06/07/1928 SSN SEX Female RAGE Caucasian
(Optional, but will help prevent misidentification) - ~,.~---
HEIGHT 5„ WEIGHT 1251bs HAIR Gray EYES ~rt~h c dry; ~}
ADDRESS Church of God Home, 801 N. Hanover Street, Carlisle PA 17013 r"'t -~ c. `- "
Y. .,' .....,i
Name of Physician Certifying Necessity of Involuntary Commitment `'r~ : < ,;.,
:: ... (Print Na ~) •_. rC
._ ~~ 'i
^,
Hospital/Facility Providing TreatmenUAddress
,..
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. , _,-i
NOTIFICATION BY (Please print name, address, area code, and telephone number of agency or~county court.'J`~
MHIMR AdministratorlReview 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 21-2012-1320 ~, Date of Court Order January 16, 2013
SfGNATURE OF NOTIFYING OFFICIAL ~~~ - Date ~ `~
..................~..~..r...Y.~.~..~~.~....~..... ~.~..... ~. ~..~.. ~......... .. ...... ~.~~.,
NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABILITY EXISTS
The physician shall provide signed confirmation of the lack of severe mental disabil'dy 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 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 subject to public disclosure.
AOPC 1285 REV. 10/26/2009! PSP No. SP4-131 (9-2009)