Financial Exploitation Reporting Form – Alabama Securities Commission

ALABAMA SECURITIES COMMISSION AND DEPARTMENT OF HUMAN RESOURCES
REPORT OF ADULT SUSPECTED TO BE FINANCIALLY EXPLOITED

For use by Qualified Individuals pursuant to Ala. Code § 8-6-170 to 179

SECTION I - INCIDENT

Date of Incident:*

Time:*

SECTION II - PERSON IDENTIFIED AT RISK OF EXPLOITATION

Last Name:*

First Name:*

MI:

Sex:*

Date of Birth:*

Race:*

Street Address:*

Phone:*

City:*

State:*

Zip:*

Responsible Party (if applicable) Power of Attorney/Guardian/Conservator:

Contact Information:*

Institution Tracking#:*

SECTION III – PERSON ALLEGEDLY RESPONSIBLE FOR EXPLOITATION

Last Name:*

First Name:*

MI:

Phone#:*

Sex:*

Race:*

Date of Birth:*

Relationship to Victim:

Address:*

Additional Information:

SECTION IV – PLEASE DESCRIBE THE INCIDENT

Required:*

SECTION V – CIRCUMSTANCES OF PERSON IDENTIFIED AT RISK

Person Identified at Risk (check descriptions that apply):*

Physical DependenceBehavioral DisordersSubstance Abuse Emotional ProblemsIntellectual DisabilityMental ProblemEconomic Dependence

SECTION VI – IF ABUSE, NEGLECT, OR OTHER FINANCIAL EXPLOITATION IS SUSPECTED PLEASE DESCRIBE

Description:

SECTION VII – REPORTER

Name of Reporter:*

Title:*

Address/Phone Number of Reporter:*

Firm Name:*

Address:*

Third Party Contacted?*

YesNo

Name:

Legal Relationship:

Third Party Contact Information:

Additional Witnesses/How to Contact:

Delayed Disbursement:*

YesNo

Financial Records Attached:*

YesNo

If yes, please attach the records here: