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 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 Pennsylvania State Police by the judge, mental health review officer or the 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 17110. 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 ________________________________________________________________________________________________ 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 Section 302(b) of the Mental Health Procedures Act and pursuant to the Uniform Firearms Act, Section 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) ____________________________________________________________________________ Signature of Physician _________________________________________________________ Date ______________________ American LegalNet, Inc. www.USCourtForms.com