Elder Abuse Complaint Form

Commonwealth of Pennsylvania

Office of Attorney General

Please explain your complaint. 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.

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 Elder Abuse 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.

1. I authorize the Elder Abuse 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 Elder Abuse 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.

I, (enter name) , 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.