STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
FOR USE BY FINANCIAL INSTITUTIONS
REPORT OF SUSPECTED DEPENDENT ADULT/ELDER
FINANCIAL ABUSE
[CONFIDENTIAL - Not subject to public disclosure]
DATE COMPLETED
TO BE COMPLETED BY REPORTING PERSON. PLEASE PRINT OR TYPE.
* FIELDS MARKED IN RED ARE REQUIRED FEILDS AND NEED TO BE FILLED IN BEFORE SUBMITTING THE FORM.
A. VICTIM
DATE OF BIRTH (mm/dd/yyyy)
SSN LANGUAGE GENDER
ADDRESS (IF FACILITY, INCLUDE NAME) CITY STATE ZIP CODE TELEPHONE
PRESENT LOCATION (IF DIFFERENT FROM ABOVE) CITY STATE ZIP CODE TELEPHONE
ELDERLY (60+) DEVELOPMENTALLY DISABLED MENTALLY ILL/DISABLED PHYSICALLY DISABLED UNKNOWN/OTHER
B. INCIDENT INFORMATION - WHERE INCIDENT OCCURRED
PLACE OF INCIDENT DATE OF INCIDENT (mm/dd/yyyy) TIME OF INCIDENT ONGOING
IF OTHER IS SELECTED SPECIFY
C. REPORTERS OBSERVATIONS, BELIEFS, AND STATEMENTS BY VICTIM IF AVAILABLE. PROVIDE ANY KNOWN TIMEFRAME (2 days, 1 week, ongoing, etc.)
(MAX 1000 CHARACTERS)
EXPLAIN
(MAX 500 CHARACTERS)
(See definition in section "Reporting Responsibilities and Time Frames" within the General Instructions)
If this is an emergency situation please contact your local police department or dial 911. If you are reporting a situation that involves imminent danger or serious bodily injury, such as physical or sexual abuse, you must call Placer County's 24-hour Adult Intake hotline at: 916-787-8860.
EXPLAIN
(MAX 500 CHARACTERS)
LIST ANY POTENTIAL DANGER FOR INVESTIGATOR (animals, weapons, communicable diseases, etc.) OR CONCERNS ABOUT THE CLIENT'S MENTAL HEALTH.
(MAX 500 CHARACTERS)
CHECK IF THERE ARE MEDICAL, FINANCIAL (ACCOUNT INFORMATION, ETC.), PHOTOGRAPHS, OR OTHER SUPPLEMENTAL INFORMATION ATTACHMENTS.
Any supplemental attachments including photographs, medical and financial records MUST be forwarded to Placer County APS by fax 530-265-9376 or sent by US Mail to: Placer County APS, 101 Cirby Hills Drive, Roseville, CA 95678.
D. TARGETED ACCOUNT
  TYPE OF ACCOUNT
 
TRUST ACCOUNT POWER OF ATTORNEY DIRECT DEPOSIT OTHER ACCOUNTS
E. SUSPECT INFORMATION
FIRST NAME AGE DATE OF BIRTH (mm/dd/yyyy)
RELATION
ADDRESS CITY STATE ZIP CODE TELEPHONE
F. OTHER PERSON BELIEVED TO HAVE KNOWLEDGE OF ABUSE (family, significant others, neighbors, medical providers, agencies involved, etc.)
LAST NAME FIRST NAME RELATIONSHIP
ADDRESS CITY STATE ZIP CODE TELEPHONE
G. TELEPHONE AND WRITTEN REPORTS TO OTHER AGENCIES
TELEPHONE REPORT MADE TO DATE OF INCIDENT (mm/dd/yyyy) TIME OF INCIDENT
LAST NAME OF OFFICIAL CONTACTED BY PHONE FIRST NAME OF OFFICIAL CONTACTED BY PHONE TELEPHONE
TITLE
STATE ZIP
WRITTEN REPORT SENT TO Enter information about the agency receiving a copy of this report. Do not submit report to California Department of Social Services Adult Programs Bureau.
AGENCY NAME
ADDRESS CITY STATE ZIP
FAX
DATE MAILED (mm/dd/yyyy)
MAILED
DATE FAXED
FAXED
DATE DROPPED OFF
DROPPED OFF
If this is an emergency situation please contact your local police department or dial 911. If you are reporting a situation that involves imminent danger or serious bodily injury, such as physical or sexual abuse, you must call Placer County's 24-hour Adult Intake hotline at: 916-787-8860. Please see the following definitions for reference:
● Imminent Danger is defined as: A substantial probability that an elder or dependent adult is in imminent risk of death or serious physical harm, through either his/her own inaction, or as a result of the action or inaction of another person.
● Serious Bodily Injury is defined as: An injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of function of a bodily member, organ or of mental faculty, or requiring medical intervention including, but not limited to, hospitalization, surgery, or physical rehabilitation.
SUBMIT REPORT
● There is no ability to print this APS report. Once submitted, an Acknowledgement Letter is generated for your records that can be printed. This is your confirmation that the report has been received.
● This online report satisfies both the telephone and written report requirements for Mandated Reporters.
REPORT OF SUSPECTED DEPENDENT ADULT/ELDER FINANCIAL ABUSE
FINANCIAL INSTITUTIONS ONLY
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 http://www.dss.cahwnet.gov/cdssweb/On-lineFor_298.htm#SOC.
An "elder" is any person residing in California who is 60 years of age or older. A "dependent adult" is anyone residing in California who is between the ages of 18 and 59 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. It also includes any person between the ages of 18 and 59 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 http://www.dss.cahwnet.gov/pdf/apscolist.pdf for a list of APS offices by county or http://www.aging.state.ca.us/html/programs/ombudsman_contacts.html 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(d)(1)).
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.
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 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.
SOC 342 (12/06)