COMMONWEALTH 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(g)(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 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 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: 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(i.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. COUNTY OF COMMITMENT OR ADJUDICATION / / INDIVIDUAL INFORMATION - INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCAPACITATED, ETC. LAST NAME JR., ETC. DATE OF BIRTH HEIGHT ADDRESS Name of Physician Certifying Necessity of Involuntary Commitment (Print Name) FIRST MAIDEN NAME / / WEIGHT SSN HAIR ALIAS SEX EYES MIDDLE RACE (Optional, but will help prevent misidentification) ' " Hospital/Facility Providing Treatment/Address NOTIFICATION BY (Please print name, address, area code, and telephone number of agency or county court.) MH/MR Administrator/Review Officer Address Telephone 303-304 Commitments require the Judge/Review Officer name authorizing the commitment, case number, & order date. Name of Judge/Review Officer (Print Name) Court Case Number SIGNATURE OF NOTIFYING OFFICIAL Date of Court Order 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 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) American LegalNet, Inc. www.FormsWorkFlow.com