Alle. Cnty. Pa. XIV app I
COMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Uniform Firearms Act, 18 PA. C.S. 6105(c)(4) specifies that it shall be unlawful for any person adjudicated as a incompetent or who has been involuntarily committed to a mental institution for inpatient care and treatment under 302, 303, 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: Firearm Unit, 1800 Elmerton Avenue, Harrisburg, PA 17100. NOTE: The envelope shall be marked "CONFIDENTIAL."
Place an "X" on either Involuntary Commitment or Adjudicated Incompetent INVOLUNTARY COMMITMENT _______ ADJUDICATED INCOMPETENT _______ Date of Involuntary Commitment or Adjudicated Incompetent ___________________________ INDIVIDUAL INFORMATION (INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT)
LAST NAME _____________________ FIRST ________________ MIDDLE ________ JR., ETC. _________ MAIDEN NAME ______________ ALIAS _______________________ DATE OF BIRTH _______________ SOCIAL SECURITY NUMBER __________________ SEX _____ RACE _____ HEIGHT _____ WEIGHT _____ HAIR _____ EYES _____ ADDRESS ___________________________________________________________________
NOTIFICATION BY (Please print name, address, area code, and phone number of agency or county court.) County Submitting Notification ___________________________________________________ County Mental Health and Mental Retardation Administrator ___________________________ County Mental Health Review Officer _____________________________________________ Physician Certifying Necessity of Involuntary Commitment ____________________________ (Required in accordance with 6105(c)(4) of the Uniform Firearms Act) Hospital/Facility Providing Treatment/Address _______________________________________ _____________________________________________________________________________ Judge ________________________________________________________________________ SIGNATURE OF NOTIFYING OFFICIAL ______________________ DATE _____________ Court Case Number ___________________ Date of Court Order _________________________
****************************************************************************** *******NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE
MENTAL DISABILITY EXISTS
The physician shall provide signed confirmation of the determination of the lack of severe mental disability following the initial examination under 302(b) of the Mental Health Procedures Act and pursuant to the Uniform Firearms Act, 6111.1(g)(3). Notice shall be transmitted by the physician to the Pennsylvania State Police through the county mental health and mental retardation administrator or mental health review officer.
Name of Physician (Please print) ___________________________________________________
Alle. Cnty. Pa. XIV app I