To fulfill your obligations under the Protect Vulnerable Adults from Financial Exploitation Act, report both the suspected financial exploitation and any related delay of transactions or disbursements via this form and to Kansas Adult Protective Services, a division of the Department for Children and Families.
PART A: THE REPORTING FIRM. Please provide your firm’s name and the other requested information so we can contact you about your firm’s report. Fields marked with an asterisk (*) are required.
*Firm Name: *Your First and Last name: Your Title: *Your Email Address: *Your Telephone Number: *Firm CRD Number: Did an agent, investment adviser representative, or person serving in a supervisory, compliance, or legal capacity for your firm alert the firm about the suspected financial exploitation described in this report? Yes No Reporting individual's first and last name: Reporting individual's address: Reporting individual's city, state, and zip code: Reporting individual's telephone number: Reporting individual's email address: Reporting Official is (check all that apply): Agent Broker-Dealer Investment Adviser Investment Adviser Representative A person who serves in a supervisory, compliance, or legal capacity for a broker-dealer or investment adviser How are you and your firm connected to the elder person or dependent adult identified below in Part B?
PART B: THE ELDER PERSON OR DEPENDENT ADULT. Please provide information about the adult who is aged 60 or older or is unable to protect his or her own interests and may be experiencing financial exploitation.
*Protected adult's name: *Protected adult's address: *Protected adult's city, state, and zip code: Protected adult's telephone number: Protected adult's email address: Protected adult's sex M/F: Protected adult's date of birth MM/DD/YYYY: Is another person responsible for the care of this person? Yes No Caregiver's name: Caregiver's address: Caregiver's city, state, and zip code: Caregiver's telephone number: Caregiver's email address: Caregiver's relationship to elder person or dependent adult:
PART C: THE PERSON(S) ALLEGEDLY RESPONSIBLE FOR FINANCIAL EXPLOITATION: Please provide as much information as possible below about the person(s) that are allegedly responsible for the suspected financial exploitation.
*Suspected exploiter's name: Suspected exploiter's address: *Suspected exploiter's city, state, and zip code: Country of suspected exploiter if not the United States: Suspected exploiter's telephone number: Suspected exploiter's email address: *Suspected exploiter's relationship to the protected adult: Suspected exploiter's sex M/F: Suspected exploiter's date of birth MM/DD/YYYY: Websites, social media accounts, usernames, other platforms associated with suspected exploiter: Are any other persons suspected of engaging in the financial exploitation you are reporting here? Yes No Please provide information about other persons suspected of engaging in the reported financial exploitation to the Director of Compliance, Enforcement, and Anti-Fraud, 785.296.5203, or the Chief of Enforcement, 785.291.3115.
PART D: SUSPECTED FINANCIAL EXPLOITATION. Financial exploitation involves the improper use, control, or withholding of a person’s property, income, or monetary resources in a way that is not for the benefit of the potential victim, but rather for the benefit of the person seeking to use or control the property. It can involve abuse of trusted relationships, use of deception, coercion, or undue influence, or taking advantage of a person’s lack of capacity to consent to the use of property.
*Please briefly explain why you suspect that financial exploitation of the protected adult may have occurred, been attempted, or is being attempted and the circumstances of the possible exploitation. Date(s) of suspected financial exploitation: Has your firm submitted or does your firm plan to submit the information in this report to an agency other than the Kansas Department of Insurance or APS? Yes No Other agency name: Other agency contact: Other agency contact telephone number: Other agency contact email address:
PART E: DELAY OF TRANSACTION OR DISBURSEMENT
*Did the broker-dealer or investment adviser delay a disbursement or transaction because of the suspected financial exploitation? Yes No If YES, answer the questions below. If NO, go to part F. *Date disbursement or transaction first delayed DD/MM/YYYY: Name of proposed recipient of funds or transfer: Address of proposed recipient: City, state, and zip code of proposed recipient: Amount of requested disbursement or transaction: Was the proposed disbursement or transaction in connection offer or sale of securities? Yes No If yes, explain. Please explain why you believe the requested disbursement or transaction might have furthered the financial exploitation you are reporting. Names of other parties to proposed transaction not identified above:
PART F: UPLOAD RECORDS. The more information you provide, the better the Kansas Department of Insurance and APS can collaborate with you and the other interested parties to resolve the matter reported. If you wish to provide documents or other information after you submit your report, please contact the Director of Compliance, Enforcement, and Anti-Fraud, 785.296.5203, or the Chief of Enforcement, 785.291.3115. No record made available to the Department or other agencies under HB 2562 shall be considered a public record under the open records act, K.S.A. 45-215 et seq., and amendments thereto.
