Financial Exploitation Complaint

PURPOSE

This form documents suspected financial exploitation of an elder or vulnerable adult. Financial exploitation includes theft, fraud, scams, misuse of funds, undue influence, and abuse of fiduciary positions. Use this form to organize information before reporting to:

• Adult Protective Services (APS)
• Local Law Enforcement
• State Attorney General's Office
• FBI (for scams and fraud)
• Financial institutions

EMERGENCY NOTICE

If exploitation is ongoing and funds are at immediate risk:
1. Contact the financial institution immediately to freeze accounts
2. Call local law enforcement
3. Report to Adult Protective Services
4. Consult with an elder law attorney about emergency protective orders

SECTION 1: VICTIM INFORMATION

1.1 Victim's Personal Information

Full Name: _______________________________________________

Date of Birth: _______________________________________________

Age: _______________________________________________

Address:
_______________________________________________
_______________________________________________

Phone: _______________________________________________

Email: _______________________________________________

1.2 Victim's Capacity

Is the victim able to manage their own financial affairs?
☐ Yes - Fully capable
☐ Partially - Has some cognitive decline
☐ No - Has significant cognitive impairment
☐ Unknown

Has the victim been declared legally incapacitated?
☐ No
☐ Yes - Guardian/Conservator: _______________________________________________

Does the victim have dementia or memory impairment?
☐ Yes ☐ No ☐ Unknown

1.3 Victim's Living Situation

Where does the victim live?
☐ Own home
☐ With family member: _______________________________________________
☐ Assisted living: _______________________________________________
☐ Nursing home: _______________________________________________
☐ Other: _______________________________________________

SECTION 2: REPORTER INFORMATION

Your Name: _______________________________________________

Relationship to Victim: _______________________________________________

Address:
_______________________________________________
_______________________________________________

Phone: _______________________________________________

Email: _______________________________________________

Are you a mandated reporter? ☐ Yes ☐ No

SECTION 3: TYPE OF FINANCIAL EXPLOITATION

3.1 Type of Exploitation (Check All That Apply)

THEFT AND FRAUD:
☐ Cash stolen from home
☐ Valuables/property stolen
☐ Unauthorized credit/debit card use
☐ Unauthorized checks written/forged
☐ Unauthorized bank withdrawals
☐ Identity theft
☐ Account takeover

ABUSE OF TRUST/FIDUCIARY ABUSE:
☐ Misuse of Power of Attorney
☐ Misuse of Guardianship/Conservatorship
☐ Misuse of Representative Payee authority
☐ Misuse of joint account access
☐ Trustee misconduct

UNDUE INFLUENCE:
☐ Pressure to change will or trust
☐ Pressure to add name to deed
☐ Pressure to add name to accounts
☐ Pressure to give gifts or loans
☐ Pressure to change beneficiary designations
☐ Isolation from family/friends

SCAMS AND FRAUD:
☐ Lottery/prize scam
☐ Grandparent/emergency scam
☐ Romance scam
☐ IRS/Government impersonation scam
☐ Tech support scam
☐ Contractor/home repair scam
☐ Investment fraud
☐ Charity scam
☐ Other scam: _______________________________________________

FAILURE TO PROVIDE:
☐ Caregiver not using victim's funds for victim's care
☐ Diversion of Social Security or pension
☐ Failure to pay victim's bills with victim's money

OTHER:
☐ _______________________________________________

SECTION 4: DETAILS OF EXPLOITATION

4.1 Description of What Happened

Describe the financial exploitation in detail:
(Include specific transactions, amounts, dates, and how you became aware of the exploitation)

_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________

4.2 Timeline

When did the exploitation begin? _______________________________________________

When was it discovered? _______________________________________________

Is it ongoing? ☐ Yes ☐ No ☐ Unknown

How long did it occur? _______________________________________________

4.3 Financial Impact

Estimated total amount of loss: $_______________________________________________

Breakdown of losses:

Has any money been recovered?
☐ No
☐ Yes - Amount: $_______________________________________________

SECTION 5: SUSPECTED PERPETRATOR(S)

5.1 Primary Suspect

Name: _______________________________________________

Relationship to Victim:
☐ Spouse/Partner
☐ Adult child
☐ Grandchild
☐ Other family member: _______________________________________________
☐ Caregiver
☐ Friend/Acquaintance
☐ Professional (specify): _______________________________________________
☐ Stranger
☐ Unknown

Address: _______________________________________________

Phone: _______________________________________________

Email: _______________________________________________

How did this person have access to victim's finances?
☐ Power of Attorney
☐ Joint account holder
☐ Guardian/Conservator
☐ Lived with victim
☐ Had access to home
☐ Victim gave access voluntarily
☐ Obtained access through deception
☐ Other: _______________________________________________

5.2 Additional Suspects

SECTION 6: FINANCIAL ACCOUNTS AFFECTED

6.1 Bank Accounts

6.2 Credit/Debit Cards

6.3 Investment Accounts

6.4 Real Property

6.5 Other Assets

SECTION 7: EVIDENCE

7.1 Documentation Available

☐ Bank statements showing unauthorized transactions
☐ Credit card statements
☐ Cancelled checks (especially forged signatures)
☐ Wire transfer records
☐ Debit card transaction records
☐ ATM withdrawal records
☐ Financial statements
☐ Tax returns showing unexplained changes
☐ Changed will, trust, or beneficiary documents
☐ Deed transfer documents
☐ Power of Attorney document
☐ Emails or text messages
☐ Voicemails
☐ Photographs
☐ Victim's statement
☐ Witness statements
☐ Other: _______________________________________________

7.2 Location of Evidence

Where are the documents and evidence located?
_______________________________________________
_______________________________________________

7.3 Preservation of Evidence

Have steps been taken to preserve evidence?
☐ Copies of documents made
☐ Original documents secured
☐ Electronic communications saved
☐ Financial institution notified
☐ Account statements requested
☐ Other: _______________________________________________

SECTION 8: LEGAL DOCUMENTS

8.1 Existing Legal Documents

Does the victim have any of the following documents?

8.2 Changes to Legal Documents

Have any legal documents been changed recently?
☐ No
☐ Yes - Describe: _______________________________________________

Were changes made under suspicious circumstances?
☐ No
☐ Yes - Describe: _______________________________________________

SECTION 9: PRIOR INCIDENTS AND REPORTS

9.1 Prior Reports

Has this exploitation been reported to any agency?

9.2 Prior Incidents

Has the victim been exploited before?
☐ No
☐ Yes - Describe: _______________________________________________

SECTION 10: WITNESSES

10.1 People with Knowledge of the Exploitation

SECTION 11: REPORTING AGENCIES

11.1 Where to Report

☐ Adult Protective Services (APS)
Hotline: _______________________________________________

☐ Local Law Enforcement
Agency: _______________________________________________
Phone: _______________________________________________

☐ State Attorney General
Consumer Protection/Elder Abuse Unit
Phone: _______________________________________________
Website: _______________________________________________

☐ FBI
For scams, fraud, and interstate crimes
Website: ic3.gov (Internet Crime Complaint Center)
Phone: Local FBI field office

☐ FTC
For scams and identity theft
Website: reportfraud.ftc.gov
Phone: 1-877-382-4357

☐ Financial Institution
Bank/Institution: _______________________________________________
Fraud Department Phone: _______________________________________________

☐ State Securities Regulator
For investment fraud
Agency: _______________________________________________

11.2 Reports Filed

SECTION 12: LEGAL REMEDIES

12.1 Potential Legal Actions

Civil remedies that may be available:
☐ Civil lawsuit for conversion/theft
☐ Breach of fiduciary duty claim
☐ Undue influence claim
☐ Constructive trust
☐ Accounting demand
☐ Injunction/restraining order
☐ Revocation of Power of Attorney
☐ Guardianship/Conservatorship petition
☐ Bank fraud claim

Criminal charges that may apply:
☐ Theft/Larceny
☐ Fraud
☐ Forgery
☐ Identity theft
☐ Elder abuse
☐ Financial exploitation of elderly/vulnerable adult
☐ Embezzlement

12.2 Attorney Consultation

Have you consulted with an attorney?
☐ No
☐ Yes - Attorney: _______________________________________________
Phone: _______________________________________________

SECTION 13: PROTECTIVE MEASURES TAKEN

13.1 Steps Already Taken

☐ Bank accounts frozen or new accounts opened
☐ Credit freeze placed
☐ Power of Attorney revoked
☐ New Power of Attorney executed
☐ Guardian/Conservator petitioned for
☐ Passwords changed
☐ Mail forwarded/new address
☐ Victim moved to safe location
☐ Perpetrator's access restricted
☐ Other: _______________________________________________

13.2 Steps Still Needed

☐ _______________________________________________
☐ _______________________________________________
☐ _______________________________________________

SECTION 14: ADDITIONAL INFORMATION

Any other information that would be helpful:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________

SECTION 15: SIGNATURE

I am filing this complaint in good faith based on my knowledge and belief. I understand that providing false information may have legal consequences.

Signature: _________________________________

Printed Name: _________________________________

Date: _________________________________

ATTACHMENTS CHECKLIST

☐ Bank/financial statements
☐ Copies of checks (especially with suspicious signatures)
☐ Credit card statements
☐ Power of Attorney document
☐ Will/Trust documents
☐ Property records
☐ Correspondence with perpetrator
☐ Photographs of evidence
☐ Witness statements
☐ Other: _______________________________________________

This form is provided for informational purposes to help document and report financial exploitation. For significant losses, consult with an elder law attorney about potential civil remedies. Report suspected criminal activity to law enforcement. Financial institutions may be able to assist with fraud investigation and potential recovery.