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 

DATE OF COMMITMENT OR ADJUDICATED INCAPACITATED, ETC.  

COUNTY OF COMMITMENT OR ADJUDICATION  

    OTHER  

INDIVIDUAL INFORMATION - INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCAPACITATED, ETC. 

LAST NAME  

 

  FIRST  

 

  MIDDLE  

JR., ETC. 

 MAIDEN NAME 

DATE OF BIRTH  

SSN  

(Optional, but will help prevent misidentification) 

WEIGHT 

HAIR 

ALIAS 

SEX 

EYES 

RACE 

HEIGHT      

ADDRESS 

Name of Physician Certifying Necessity of Involuntary Commitment 

(Print Name)  

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                           

 

    Telephone  

303-304 Commitments require the Judge/Review Officer name authorizing the commitment, case number, & order date.

Address  

Name of Judge/Review Officer  

Court Case Number 

SIGNATURE OF NOTIFYING OFFICIAL  

(Print Name) 

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)