"Elder Fraud Report Form" - Alaska

Elder Fraud Report Form is a legal document that was released by the Alaska Department of Administration - a government authority operating within Alaska.

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P a g e E L D E R F R A U D R E P O R T
STATE OF ALASKA
Michael J. Dunleavy,
GOVERNOR
Department of Administration
th
900 W. 5
Avenue, Suite 525
Anchorage, AK 99501
Office of Public Advocacy,
Phone: (907) 334-5954
Anchorage Elder Fraud Section
Fax: (907) 269-1071
FRAUD REPORT FORM
ELDER INFORMATION
DATE:___________
Full Name
__________________________________________________
Mail Address
___________________________ ____________, AK ______
Date of Birth
_____, __,____
Physical Address
___________________________ ____________, AK ______
Social Security #
___________________________
Home Phone
___________________________
Cell Phone
___________________________
Marital Status
M_ S_ W_ D_
Own Y_N_
Rent Y_N_
*If Rented; Landlord:
Name _____________________________Home Phone__________________
Cell_________________
Address___________________________, AK __________
Family Members:
Name_____________________________Phone__________________Relationship___________
Name_____________________________Phone__________________Relationship___________
Name_____________________________Phone__________________Relationship___________
Name_____________________________Phone__________________Relationship___________
Former Name _____________________________Phone__________________
Address___________________________, __________
Date of Loss or Harm 1st known? ____________________
1 |
P a g e E L D E R F R A U D R E P O R T
STATE OF ALASKA
Michael J. Dunleavy,
GOVERNOR
Department of Administration
th
900 W. 5
Avenue, Suite 525
Anchorage, AK 99501
Office of Public Advocacy,
Phone: (907) 334-5954
Anchorage Elder Fraud Section
Fax: (907) 269-1071
FRAUD REPORT FORM
ELDER INFORMATION
DATE:___________
Full Name
__________________________________________________
Mail Address
___________________________ ____________, AK ______
Date of Birth
_____, __,____
Physical Address
___________________________ ____________, AK ______
Social Security #
___________________________
Home Phone
___________________________
Cell Phone
___________________________
Marital Status
M_ S_ W_ D_
Own Y_N_
Rent Y_N_
*If Rented; Landlord:
Name _____________________________Home Phone__________________
Cell_________________
Address___________________________, AK __________
Family Members:
Name_____________________________Phone__________________Relationship___________
Name_____________________________Phone__________________Relationship___________
Name_____________________________Phone__________________Relationship___________
Name_____________________________Phone__________________Relationship___________
Former Name _____________________________Phone__________________
Address___________________________, __________
Date of Loss or Harm 1st known? ____________________
2 |
P a g e E L D E R F R A U D R E P O R T
Does elder have capacity? Yes__ No__
*If no; who has information regarding capacity such as Doctors?
Name _____________________________Phone__________________Fax_________________
Address___________________________, AK __________
Has elder given Power of Attorney to another person? Yes_No_
Date given___________
Name________________________________________
Address______________________________________
Phone_____________ Hm_Cell_Fax_______________
Has it POA been revoked? Y_N_ When? ____________
Does elder live with anyone else? Y_N_
*If yes; who:
Name_____________________________Phone__________________Relationship___________
Name_____________________________Phone__________________Relationship___________
Name_____________________________Phone__________________Relationship___________
Name_____________________________Phone__________________Relationship___________
Does elder have a Guardian? Y_N_
*If yes; who:
Name_____________________________Phone__________________Fax_________________
Does elder have a Conservator? Y_N_
*If yes; who:
Name_____________________________Phone__________________Fax_________________
Does elder have a caregiver? Y_N_
*If yes; who:
Name_____________________________Phone__________________Fax_________________
Address___________________________, __ __________
Is the caregiver from an agency? Y_N_
*If yes; agency:
Name_____________________________Phone__________________Fax_________________
Address___________________________, __ __________
Does elder have an Attorney? Y_N_
*If yes; who:
Name_____________________________Phone__________________Fax_________________
Address___________________________, __ __________
Does the elder have a Physician? Y_N_
Name_____________________________Phone__________________Fax_________________
Address___________________________, __ __________
3 |
P a g e E L D E R F R A U D R E P O R T
Where does elder bank?
Name_____________________________Phone__________________Fax_________________
Address___________________________, __ __________Account #____________________
Name_____________________________Phone__________________Fax_________________
Address___________________________, __ __________Account #____________________
Name_____________________________Phone__________________Fax_________________
Address___________________________, __ __________Account #____________________
Does elder have a credit card? Y_N_
*If yes: Company:
Name_____________________________Phone__________________Fax_________________
Address___________________________, __ __________Account #____________________
Name_____________________________Phone__________________Fax_________________
Address___________________________, __ __________Account #____________________
Does elder have a will? Y_N_
Has it been filed with the courts? Y_N_
*If yes: Where?
Name_____________________________Phone__________________Fax_________________
Address___________________________, __ __________
Has anyone asked elder to change the will? Y_No_
*If yes who:
Name_____________________________Phone__________________Fax_________________
Address___________________________, __ __________
Does elder have a Trust? Y_N_
Has it been filed with the courts? Y_N_
*If yes: Where?
Name_____________________________Phone__________________Fax_________________
Address___________________________, __ __________
Who pays elder’s bills?
Name_____________________________Phone__________________Fax_________________
Address___________________________, __ __________
Does elder run out of money at the end of the month? Y_No_
Does elder regret or worry about financial decisions that have been made by him/her? Y_N_
Why or what information leads you to believe fraud is occurring?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
4 |
P a g e E L D E R F R A U D R E P O R T
Do you have copies of a POA, Trust, any docs to back up incident? Y_N_
REPORTER INFORMATION
Full Name___________________________________Agency Name_______________
Mail Address
___________________________ ____________, AK ______
Physical Address
___________________________ ____________, AK ______
Relationship to elder
___________________________
Home Phone
___________________________
Cell Phone
___________________________
Have other agencies been contacted, such as police APS? Y_N_ Date contacted_____________
*If yes: who:
Name_____________________________Phone__________________Fax_________________
Address___________________________, __ __________
Name_____________________________Phone__________________Fax_________________
Address___________________________, __ __________
POTENTIAL DEFENDANT’S INFORMATION
Name_____________________________Phone__________________
Relationship__________________
DOB____________________
Address___________________________, __ __________
Name_____________________________Phone__________________
Relationship__________________
DOB____________________
Address___________________________, __ __________
Name_____________________________Phone__________________
Relationship__________________
DOB____________________
Address___________________________, __ __________
Does potential defendant limit victim’s access to money? Transportation? Phone? Y_N_
*If yes; How?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
5 |
P a g e E L D E R F R A U D R E P O R T
Does potential defendant destroy personal belongings of victim? Y_N_
*If yes; How?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Are there any threats to physical safety of others including elder? Y_N_
*If yes; by whom:
Name_____________________________How:______________________________________
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____________________________________________________________________________
Name_____________________________How:______________________________________
_____________________________________________________________________________
Is there excess use of guilt or intimidation to the elder? Y_N_
*If yes; by whom:
Name_____________________________How:______________________________________
____________________________________________________________________________
Name_____________________________How:______________________________________
_____________________________________________________________________________
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