Pennsylvania Office of Attorney General

Elder Abuse Complaint Form

Commonwealth of Pennsylvania

Office of Attorney General

Victim's Age Group (for Statistical and Enforcement Purposes Only)




Victim's Information (* indicates required field)

 
 

  
 
 
 
 
 
 
 

Your Information (* indicates required field)

 
 
 
 
 

Complaint Information (* indicates required field)

 
 
 

Complaint Description (* indicates required field)

Please explain your complaint. Try to be brief, but be sure to 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.


Authorization

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. 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.

 

By signing below:

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, , 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.