Josh Shapiro Attorney General seniors@attorneygeneral.gov www.attorneygeneral.gov Senior Protection Complaint Form Senior Protection Unit 16th Floor, Strawberry Square Harrisburg, PA 17120 1-866-623-2137 (Help Line) TO REPORT AN EMERGENCY CASE OF ELDER ABUSE DIAL 9-1-1 OR BY CALLING ADULT PROTECTIVE SERVICES 1-800-490-8505 Required fields are marked with an asterisk* Are you a veteran? Yes No Are you on active duty? Yes No Age Group: Under 18 18-34 35-59 60-64 65 and older Mr. Ms. Mrs. Dr. Name * Address * City * State * Zip Code * County * Daytime Phone Number ( ) Home Phone Number ( ) Email Address If you are filling this form out on behalf of someone else, please submit your information: Are you a veteran? Yes No Are you on active duty? Yes No Ag e Group: Under 18 18-34 35-59 60-64 65 and older Mr. Ms. Mrs. Dr. Name * Address * City * State * Zip Code * County * Daytime Phone Number * ( ) Home Phone Number * ( ) Email Address Who is the complaint against? Name Phone Number: ( ) Address City State Zip Code County American LegalNet, Inc. www.FormsWorkFlow.com This complaint is regarding (Check All That Apply) Physical Abuse Neglect of Care Financial Exploitation Scam/Fraud Consumer Issues Healthcare Services Other Concerns Complaint Information: Please explain your complaint. You may use additional sheets if necessary. Please print or type clearly. Try to be brief, but be sure to tell us WHAT happened, WHEN it happened, and WHERE it happened. Be specific about any oral statements that were made to you. Describe events in the order in which they happened. Attach COPIES of all solicitations, letters, receipts, cancelled checks (front & back), advertisements and any other papers that relate to your complaint. American LegalNet, Inc. www.FormsWorkFlow.com PLEASE READ CAREFULLY THE ATTORNEY GENERAL CANNOT ACT AS YOUR PRIVATE ATTORNEY The primary function of the Office of Attorney General is to represent the public at large. The Senior Protection Unit may mediate your complaint if it falls within the jurisdiction of this office. Be advised that the information you provide may be shared with the party you have complained about and may be shared with or referred to other law enforcement or regulatory agencies. Your complaint will be kept on file with our office and the information may be used to establish violations of Pennsylvania law. By signing below: 1. I authorize the Senior Protection Unit to provide a copy of this complaint to any person or entity about which I am complaining; and to any person or provider possessing medical and insurance records or information related to this complaint. 2. I authorize the Senior Protection Unit to transfer my complaint to another federal, state, local, or other agency, which may have jurisdiction over this matter. This authorization extends to any and all attachments which may be part of my case file, including any medical records the Office may obtain pursuant to a medical release. Additional information may be requested. I certify that the information provided in this complaint form, including my identity and any factual statements or allegations, are true and correct to the best of my knowledge, information, and belief. YOUR SIGNATURE DATE OFFICE USE ONLY Di sposition of the complaint date Name OAG Unit Agent Complaint # Outside referral to By American LegalNet, Inc. www.FormsWorkFlow.com