COMMONWEALTH OF PENNSYLVANIA COURT NOTIFICATION OF PROHIBITING OFFENSE UNLAWFUL USER OF CONTROLLED SUBSTANCE In accordance with 18 Pa.C.S. § 6111.1(f)(1)(ii), Notwithstanding any statute to the contrary, judges of the courts of common pleas shall notify the Pennsylvania State Police of any finding of fact or court order related to any person described in 18 U.S.C. § 922(g)(3), relating to persons who are unlawful users of or addicted to any controlled substance (as defined in section 102 of the Controlled Substances Act [21 U.S.C. 802]). The notification shall be transmitted by the judge within seven days of the finding of fact or court order by first class mail to the Pennsylvania State Police, Attention: PICS Unit, 1800 Elmerton Avenue, Harrisburg, PA 17110. (Please type or print clearly with a black or blue ballpoint ink pen.) Pursuant to federal guidelines, inference of current drug use includes but is not limited to the following: a conviction for a drug offense in the past year; an admission of drug use or dependency in a criminal or civil proceeding; a positive drug test of a person, paraphernalia, or substance, regardless of the offense that is being adjudicated or has been adjudicated. This is not an exhaustive list; inference of use may be determined any number of ways, as long as the conduct, drug test, conviction, etc., occurred within the past year. SUBJECT INFORMATION Last Name Date of Birth Street Address SID No. Sex Race OTN Height Weight / / First Name SSN (Optional, but will help prevent misidentification) City Court Docket No. Hair Middle Name - State Zip Code County Submitting Notification Eyes AOPC 2251 REV. 05/03/2010 / PSP No. SP4-138 (9-2009) American LegalNet, Inc. www.FormsWorkFlow.com UNLAWFUL USER/OFFENSE INFORMATION (A copy of the court order or finding of fact may be attached to this form.) Title/Section Subsection Description Grade Disposition Date of Conviction, Positive Drug Test, Admission of Use, etc. Name of Notifying Official Please Print Name Signature of Notifying Official 27 C.F.R. § 478.11 UNLAWFUL USER OF OR ADDICTED TO ANY CONTROLLED SUBSTANCE n n n Date / / A person who uses a controlled substance and has lost the power of self-control with reference to the use of the controlled substance; and any person who is a current user of a controlled substance in a manner other than as prescribed by a licensed physician. Such use is not limited to the use of drugs on a particular day, or within a matter of days or weeks before, but rather that the unlawful use has occurred recently enough to indicate that the individual is actively engaged in such conduct. A person may be an unlawful current user of a controlled substance even though the substance is not being used at the precise time the person seeks to acquire a firearm or receives or possesses a firearm. An inference of current use may be drawn from evidence of a recent use or possession of a controlled substance or a pattern of use or possession that reasonably covers the present time. For example: · · · A conviction for use or possession of a controlled substance within the past year; Multiple arrests for such offenses within the past five years if the most recent arrest occurred within the past year; or Persons found through a drug test to use a controlled substance unlawfully, provided that the test was administered within the past year. n For a current or former member of the Armed Forces, an inference of current use may be drawn from recent disciplinary or other administrative action based on confirmed drug use, e.g., court-martial conviction, nonjudicial punishment, or an administrative discharge based on drug use or drug rehabilitation failure. As defined in 21 U.S.C. § 802 and 21 C.F.R. Part 1308, the term "controlled substance" includes but is not limited to marijuana, depressants, stimulants, and narcotic drugs. The term "controlled substance" does not include distilled spirits, wine, malt beverages, or tobacco (as those terms are defined or used in Subtitle E of the Internal Revenue Code of 1986, as amended). PRIVACY ACT NOTICE: Solicitation of this information is authorized under Title 18 Pa. C.S. § 6111.1. 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 2251 REV. 05/03/2010 / PSP No. SP4-138 (9-2009) American LegalNet, Inc. www.FormsWorkFlow.com