Vulnerable Adult Report - Arkansas Securities Department

Instructions:

For use by Qualified Individuals, a registered agent, or investment adviser representative or person who serves in a supervisory, compliance or legal capacity for a broker-dealer or investment adviser.

Section 1 – Incident

Date of Incident(Required)

Section 2 – Person Identified at Risk of Exploitation

Year of Birth

Phone(Required)

Name and Role(Required)

Contact Information(Required)

Section 3 – Person Allegedly Responsible for Exploitation

Year of Birth

Relationship to Victim(Required)

Phone(Required)

Additional Information

Section 4 – Please Describe the Incident

Describe the Incident

Section 5 – Circumstances of Person Identified at Risk

Section 6 – If Abuse, Neglect, or Other Financial Exploitation is Suspected, Please Describe

If Abuse, Neglect, or Other Financial Exploitation is Suspected, Please Describe

Section 7 – Reporter of Incident

Reporter Email(Required)

Title

CRD No.

Reporter Phone(Required)

Firm Name

CRD No.

Legal Relationship to Victim(Required)

Phone(Required)

Additional Witnesses/Contact Information(Required)

Section 8 – Disbursement of Funds or Securities

Date disbursement requested(Required)

Date disbursement delayed(Required)

Questions?

Questions or concerns regarding reports may be directed to lindy.streit@arkansas.gov or (501) 324-8672.

CAPTCHA

(800) 981-4429

Instructions:

Section 1 – Incident

Section 2 – Person Identified at Risk of Exploitation

Section 3 – Person Allegedly Responsible for Exploitation

Section 4 – Please Describe the Incident

Section 5 – Circumstances of Person Identified at Risk

Section 6 – If Abuse, Neglect, or Other Financial Exploitation is Suspected, Please Describe

Section 7 – Reporter of Incident

Section 8 – Disbursement of Funds or Securities

Questions?