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


    SECTION II - PERSON IDENTIFIED AT RISK OF EXPLOITATION


    SECTION III – PERSON ALLEGEDLY RESPONSIBLE FOR EXPLOITATION


    SECTION IV – PLEASE DESCRIBE THE INCIDENT


    SECTION V – CIRCUMSTANCES OF PERSON IDENTIFIED AT RISK

    Physical DependenceBehavioral DisordersSubstance Abuse Emotional ProblemsIntellectual DisabilityMental ProblemEconomic Dependence


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


    SECTION VII – REPORTER