FOR USE BY FINANCIAL INSTITUTIONS

REPORT OF SUSPECTED DEPENDENT ADULT OR ELDER FINANCIAL ABUSE

FOR USE BY FINANCIAL INSTITUTIONS
Date Completed

MonthDayYear
Date
CONFIDENTIAL REPORT - NOT SUBJECT TO PUBLIC DISCLOSURE
A) VICTIM INFORMATION
Name (Last Name, First Name)*
Age*
Date of Birth*
Social Security Number
Gender*

MaleFemale
Language*

Non-VerbalEnglishOther
Address*

Street Address (If Facility, Include Name)

Street Address Line 2

CityState / Province

Zip Code
Telephone
Present Location (If Different From Above)
City
Zip Code
Telephone
Additional victim information:

Elderly (65+)Own HomeMentally Ill or DisabledPhysically DisabledUnknown/other
B) INCIDENT INFORMATION - WHERE INCIDENT OCCURRED
Place of Incident (Check One)*

Financial InstitutionOwn HomeCare FacilityUnknownOther (Specify)
Address Where Incident(s) Occurred*
Date/Time of Incident(s)*

MonthDayYear
Date
Hour MinutesAM/PM Option
c) REPORTER'S OBSERVATIONS
Describe what was observed*
D) TARGETED ACCOUNT
Account Number: (Last 4 Digits)*
Type of Account*

DepositCreditOther
Trust Account:*

NoYes
Power of Attorney*

YesNo
Direct Deposit?*

YesNo
Other Account?*

YesNo
E: SUSPECT INFORMATION
Name of Suspected Abuser(s)
Date of Birth

MonthDayYear
Date
Age (Estimate If Unknown)
Address
Relationship to Victim

Care CustodianParentSon/DaughterHealth PractitionerSpouseUnknownOther
F. OTHER PERSON(S) BELIEVED TO HAVE KNOWLEDGE OF ABUSE
Name
Date of Birth

MonthDayYear
Date
Age (estimate if unknown)
Address
G) TELEPHONE AND WRITTEN REPORTS
TELEPHONE REPORT MADE TO

Local APSLocal Law EnforcementLocal Ombudsman
Name of Official Contacted by Phone:
Telephone
Date/Time

MonthDayYear
Date
Hour MinutesAM/PM Option
Reported By
Title
Telephone
Date/Time

MonthDayYear
Date
Hour MinutesAM/PM Option
Name of Financial Institution
Address
WRITTEN REPORT SENT TO:

Enter information about the agency recieving a copy of this report.
Name of Agency
Address or Fax
Sent via:

MailFax
Date Sent

MonthDayYear
Date
Date Faxed

MonthDayYear
Date
GENERAL INSTRUCTIONS
PURPOSE OF THE FORM
This form is to be used by officers and employees of financial institutions (“mandated reporter(s)”) to report suspected financial abuse suffered by a dependent adult or elder. Other types of dependent adult or elder abuse may be reported using form SOC 341. This form is available on https://www.cdss.ca.gov/inforesources/ forms-brochures/forms-alphabetic-list/q-t.

For purposes of mandatory reporting, an “elder is any person residing in California who is 65 years of age or older (WIC section 15610.27 A “dependent adult” is anyone residing in California who is between the ages of 18 and 64 years, who has physical or mental limitations that restrict his or her ability to carry out normal activities or to protect his or her rights, including, but not limited to, persons whose physical or mental disabilities have diminished because of age (WIC section 15610.23 It also includes any person between the ages of 18 and 64 who is admitted as an inpatient to a 24-hour health facility.

The oral or written report may be made to the adult protective services agency (APS) in the county where the apparent victim resides, or to a law enforcement agency in the county where the incident occurred. If the mandated reporter knows the apparent victim resides in a long-term care facility, the report must be provided to the local ombudsman or local law enforcement agency. The mandated reporter must first report the incident by telephone, followed by a written report within two working days, using the form. See https://www.cdss. ca.gov/Portals/9/APS/County_APD_Contacts.pdf for a list of APS offices by county or https://aging.ca.gov/ Find_Services_in_My_County/ for county ombudsman offices.
WHAT TO REPORT
Any mandated reporter who, in his or her professional capacity, or within the scope of his or her employment has observed, suspects, or has knowledge of an incident that reasonably appears to be financial abuse, or is told by an elder or a dependent adult that he or she has experienced behavior constituting financial abuse, shall report the known or suspected instance of abuse by telephone immediately, or as soon as practicably possible, and by written report sent within two working days to the appropriate agency.
REPORTING PARTY DEFINITIONS
Officers and employees of financial institutions are mandated reporters of suspected financial abuse of an elder or dependent adult residing in California (WIC 15630.1 Financial abuse of an elder or dependent adult generally means the taking of real or personal property of an elder or dependent adult to a wrongful use, or assisting in doing so (WIC 15610.30

A mandated reporter who has direct contact with the elder or dependent adult, or who does not have direct contact but reviews or approves the elder’s or dependent adult’s financial documents, records, or transactions, and who reasonably believes that financial abuse has occurred, must report the incident by telephone immediately, or as soon as practicably possible, and by written report sent within two working days to the local adult protective services agency or the local law enforcement agency (WIC 15630.1(d1
IDENTITY OF THE REPORTING PARTY
The identity of all persons reporting suspected financial abuse shall be confidential and only disclosed among APS agencies, local law enforcement agencies, Long-Term Care Ombudsman (LTCO) coordinators, Bureau of Medi-Cal Fraud and Elder Abuse of the Office of the Attorney General, licensing agencies or their counsel, Investigators of the Department of Consumer Affairs who investigate elder and dependent adult abuse, the Office of the District Attorney, the Probate Court, and the Public Guardian, or upon waiver of the confidentiality by the mandated reporter or by court order.
MULTIPLE REPORTERS
When two or more mandated reporters are jointly knowledgeable of a suspected instance of abuse of a dependent adult or elder, and when there is agreement among them, the telephone report may be made by one member of the group. Also, a single written report may be completed by that member of the group. Any person of that group, who believes the report was not submitted, shall submit the report.
ADULT PROTECTIVE SERVICES (APS) ELIGIBILITY
For purposes of receiving APS program services, an elder is someone 60 years of age or older (WIC Section 15750(b2 As of January 1, 2022, APS agencies can receive referrals and investigate allegations of abuse and provide intervention and case management services to any elder 60 years of age or older, and to any dependent adults between the ages of 18-59 (WIC Section 15750(b1A Statutes governing mandated reporting have not been affected; accordingly, mandatory reporting still only applies to elders age 65 years and older.
FAILURE TO REPORT
Officers or employees of financial institutions (defined under “Reporting Party Definitions”) are mandated reporters of financial abuse (effective January 1, 2007 These mandated reporters who fail to report financial abuse of an elder (age 65 or older) or dependent adult are subject to a civil penalty not exceeding $1,000. Individuals who willfully fail to report financial abuse of an elder or dependent adult are subject to a civil penalty not exceeding $5,000. These civil penalties shall be paid by the financial institution, which is the employer of the mandated reporter to the party bringing the action.
WRITTEN REPORT
If any item of information is unknown, write “unknown” beside the item.

1. Part A: Victim Provide information as indicated to the extent known to you or available from financial institution records. If the apparent victim is residing at a location other than his or her address of record, indicate in “Present Location.”

2. Part B: Incident Information Please check the appropriate box to indicate where the incident occurred. If the incident occurred at another location, please enter the address of the incident location.

3. Part C: Reporter’s Observations Complete this part carefully and completely. Please include any of the following, as applicable:
- Statements made by the apparent victim or the suspect;
- Changes to banking patterns or practices; unusual account activity, such as large withdrawals or large wire transfers;
- Abrupt changes to legal or financial documents, such as a power of attorney or trust instrument;
- Sudden confusion by the apparent victim regarding his or her personal financial matters;
- Repeated telephone calls to the financial institution by the apparent victim repeatedly asking the same question(s);
- Establishment of unnecessary credit for the apparent victim himself or herself or another person;
- Apparent victim’s belief that he or she has won a lottery;
- Observations regarding changes to the apparent victim’s appearance or demeanor, etc.; or
- Other concerns by the financial institution’s officer or employee not listed above.
Please attach additional pages, if necessary.
4. Part D: Targeted Account Complete information as indicated regarding the targeted account of the apparent victim. To ensure confidentiality, indicate only the last 4 digits of that account number. When making the report by telephone, the mandated reporter will be asked to provide the full account number. A trust account includes not only a Totten or informal trust arrangement through a deposit account, but also formal trust arrangements through a financial institution’s trust department. If the apparent victim has other accounts with the financial institution, check ”yes.” If more than one account is affected, indicate on separate page.

5. Part E: Suspect Information This information is of particular importance to an agency’s ability to conduct an investigation. Attach additional pages if more than one suspect is involved.

6. Part F: Other Persons Believed to Have Knowledge of Abuse This section is intended to identify any other persons who have knowledge of the incident(s)

7. Part G: Telephone and written reports This part shall be completed by the mandated reporter for statistical reporting to financial institutions, and county, state, and federal entities.

8. Distribution of SOC 342 copies The mandated reporter shall send the original and one copy to the appropriate agency, after the telephone report is made; keep one copy for the reporter’s file. The receiving agency shall place the original copy in the case file and send a copy to the cross-reporting agency, if applicable.

DO NOT SEND A COPY TO THE CALIFORNIA DEPARTMENT OF SOCIAL SERVICES ADULT PROGRAMS OPERATIONS BUREAU.
Should be Empty:

REPORT OF SUSPECTED DEPENDENT ADULT OR ELDER FINANCIAL ABUSE

A) VICTIM INFORMATION

B) INCIDENT INFORMATION - WHERE INCIDENT OCCURRED

c) REPORTER'S OBSERVATIONS

D) TARGETED ACCOUNT

E: SUSPECT INFORMATION

F. OTHER PERSON(S) BELIEVED TO HAVE KNOWLEDGE OF ABUSE

G) TELEPHONE AND WRITTEN REPORTS

GENERAL INSTRUCTIONS

PURPOSE OF THE FORM

WHAT TO REPORT

REPORTING PARTY DEFINITIONS

IDENTITY OF THE REPORTING PARTY

MULTIPLE REPORTERS

ADULT PROTECTIVE SERVICES (APS) ELIGIBILITY

FAILURE TO REPORT

WRITTEN REPORT