Fillable FOR USE BY FINANCIAL INSTITUTIONS REPORT OF SUSPECTED (California)

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FOR USE BY FINANCIAL INSTITUTIONS REPORT OF SUSPECTED (California)

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■■ CARE CUSTODIAN ■■ PARENT ■■ SON/DAUGHTER ■■ HEALTH PRACTITIONER ■■ SPOUSE ■■ UNKNOWN ■■ OTHER___________________________________________
F. OTHER PERSON(S) BELIEVED TO HAVE KNOWLEDGE OF ABUSE - (family, significant others, neighbors, medical providers and
agencies involved, etc.)
E. SUSPECT INFORMATION
RELATIONSHIP TO VICTIM
G. TELEPHONE AND WRITTEN REPORTS
DATE OF BIRTHNAME OF SUSPECTED ABUSER(S) ADDRESS AGE (ESTIMATE IF UNKNOWN)
3. Cross-Reported to: ■■ CDHS, Licensing & Cert.; ■■ CDSS-CCL; ■■ CDA Ombudsman; ■■ Bureau of Medi-Cal Fraud & Elder Abuse; ■■ Mental Health; ■■ Law Enforcement;
■■ Professional Board; ■■ Developmental Services; ■■ APS; ■■ Other (Specify) Date of Cross-Report:
4. APS/Ombudsman/Law Enforcement Case File Number:_____________________________________
Use SOC 341 to report other types of abuse
PLACE OF INCIDENT (✔ CHECK ONE)
■■ FINANCIAL INSTITUTION ■■ OWN HOME ■■ CARE FACILITY ■■ OTHER (Specify) ■■ UNKNOWN
TO BE COMPLETED BY REPORTING PERSON. PLEASE PRINT OR TYPE.
1. Report Received by:
H. RECEIVING AGENCY USE ONLY ■■ Telephone Report ■■ Written Report
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.
■■ Local APS ■■ Local Law Enforcement ■■ Local Ombudsman
TELEPHONE REPORT MADE TO:
B. INCIDENT INFORMATION - WHERE INCIDENT OCCURRED
C. REPORTER’S OBSERVATIONS
A. VICTIM
2. Assigned ■■ Immediate Response ■■ Ten-day Response ■■ No Initial Face-To-Face Required ■■ Not APS ■■ Not Ombudsman
Approved by: Assigned to (optional):
FOR USE BY FINANCIAL INSTITUTIONS
REPORT OF SUSPECTED DEPENDENT ADULT/ELDER
FINANCIAL ABUSE
■■ ELDERLY (65+) ■■ DEVELOPMENTALLY DISABLED ■■ MENTALLY ILL/DISABLED ■■ PHYSICALLY DISABLED ■■ UNKNOWN/OTHER
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
DATE COMPLETED:
[CONFIDENTIAL - Not subject to public disclosure]
NAME (LAST NAME FIRST)
ADDRESS (IF FACILITY, INCLUDE NAME)
PRESENT LOCATION (IF DIFFERENT FROM ABOVE)
DATE/TIME OF INCIDENT(S)ADDRESS WHERE INCIDENT(S) OCCURRED
(ATTACH ADDITIONAL PAGES IF NECESSARY)
AGE DATE OF BIRTH
SSN
GENDER
■■ M ■■ F
CITY
ZIP CODE
ZIP CODE
CITY
LANGUAGE (✔ CHECK ONE)
■■ NON-VERBAL ■■ ENGLISH
■■ OTHER (
SPECIFY
)
TELEPHONE
()
TELEPHONE
()
NAME OF OFFICIAL CONTACTED BY PHONE
REPORTED BY TITLE
ADDRESS
NAME OF FINANCIAL INSTITUTION
NAME OF AGENCY ADDRESS OR FAX #
■■ Date Mailed:
■■ Date Faxed:
TELEPHONE
()
TELEPHONE
()
DATE/TIME
DATE/TIME
Date/Time:
SOC 342 (12/06)
D. TARGETED ACCOUNT
ACCOUNT NUMBER: (LAST 4 DIGITS)
POWER OF ATTORNEY:
■■ YES ■■ NO
TYPE OF ACCOUNT: ■■ DEPOSIT ■■ CREDIT ■■ OTHER
DIRECT DEPOSIT: ■■ YES ■■ NO
TRUST ACCOUNT: ■■ YES ■■ NO
OTHER ACCOUNTS:
■■ YES ■■ NO
NAME
ADDRESS TELEPHONE NUMBER RELATIONSHIP
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 65 years of age or older. A “dependent adult” is anyone residing in
California who is between the ages of 18 and 64 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 64 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 with-
in 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.
SOC 342 (12/06) GENERAL INSTRUCTIONS
PAGE 1 OF 2
GENERAL INSTRUCTIONS (Continued)
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) GENERAL INSTRUCTIONS
PAGE 2 OF 2
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FOR USE BY FINANCIAL INSTITUTIONS REPORT OF SUSPECTED (California)

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Completed 12 April 2021

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