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ELDER FINANCIAL EXPLOITATION/PATIENT ABUSE COMPLAINT FORM
         
 
  (Only New Complaints May Be Filed Online)
Please be aware of the following:
  • If this matter is an emergency, you should call 911 immediately.
  • Please also note that the filing of this complaint is not a substitute for contacting Adult Protective Services.
  • When your complaint has been submitted, you will be informed of your Web Complaint Number in your confirmation. Please make an accurate record of this number or print the confirmation page.
  • Complaints and inquiries become public records when they are submitted to the Attorney General's office, and under the Michigan Freedom of Information Act, copies may be subject to disclosure to anyone who asks for them.
  • A copy of the complaint may be sent to other governmental agencies.
  • Please be particularly cautious with information containing your Social Security number, credit card account numbers, etc. for security purposes. If you believe it is necessary to submit such information, you should mail that information and the corresponding complaint instead of sending it electronically.
  • Do not use punctuation when providing names and addresses.

NOTE:  Fields labelled in RED are required values.

           
 
  I. RESIDENT/PERSON AT RISK OF ABUSE/EXPLOITATION
  Resident Last Name:     Resident First Name:    
  Gender Identity: Race:
  Date of Birth:     Social Security # (Last 4 digits):    
  Phone:   Insurance Provider:    
  Street Address:     City:      
  State:   Zip Code:      
  County:  
  This Address is a: Facility Name:  
  Power of Attorney Last Name:   Power of Attorney First Name:    
  Work Phone:    
Guardian/Resident Representative Last Name:   Guardian/Resident Representative First Name:    
  Work Phone:    
  Conservator:   Work Phone:    
  Court Action Pending? Court:    
  File #:  
  Approximate Monetary Value:   Incident Date:      
  Financial Records Attached? Financial Institutions:    
  Represented by an Attorney? Attorney Name:    
  Work Phone:  
 
 
  II. IS THE RESIDENT/PERSON A VULNERABLE ADULT: Need assistance with Activities of Daily Living (ADL's)
18 or older Banking/Financial Decisions
Bathing Taking Medication  
Doctor Visits Getting Dressed  
Cooking Unable to Protect Self
Eating Transportation  
Walking Getting Water
65 years or older Sitting
Getting out of bed Adjudicated as Incompetent  
Other Other:  
 
 
  III. PERSON/COMPANY ALLEGEDLY RESPONSIBLE FOR ABUSE/EXPLOITATION
Company or Person?
  Last Name:     First Name:    
  Company Name:        
Street Address:     City:    
  State: Zip Code:    
  County: Phone:  
  Fax Number:   E-mail Address:  
  Web Site Address:  
  Gender Identity: Race:
  Relationship to Resident/Vulnerable Adult:   D.O.B.:    
 
 
  IV. COMPLAINANT INFORMATION (Person filing complaint)
  Your Last Name:     Your First Name:    
  MI:   Title:  
Your Street Address:     City:    
  Your State:   Zip Code:    
  County: Phone:  
  E-mail Address:    
  Web Address:   Relationship to Resident/Vulnerable Adult:  
  Firm/Company Name:   Phone:  
  Firm Address:   Firm City:  
  Firm State: Zip Code:  
Represented by an Attorney: Name:  
  Phone:  
 
 
  V. REPORTING
           
  Law Enforcement Notified:   Agency:    
  Police Report #:  
  Complaint Filed with APS
  Date:      
  Complaint Filed with other State Agencies (e.g. MDHHS, LARA BCHS) Agency:  
  Willing to Testify:
 
 
  Description of Alleged Abuse    
 

Please provide any additional relevant information in chronological order, including dates, names, addresses, telephone numbers, and account numbers where possible. You have approximately 8-10 typed pages and you may paste text from word processing documents.

 
           
 
 
 
 
 
   
   
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