REPORT OF SUSPECTED FINANCIAL EXPLOITATION

REV. NOVEMBER 2017

FILED WITH THE TEXAS STATE SECURITIES BOARD PER SECTION 45 OF THE SECURITIES ACT

You may use this form to report financial exploitation pursuant to Section 45 of the Securities Act to submit any records relating to

the suspected financial exploitation, and to provide information requested pursuant to Board Rule 115 and/or 116. You should

send the completed form and any relevant records by electronic mail to [email protected]. Alternatively, you may

send the form and any relevant records by regular mail addressed to ATTN: Director of Enforcement, Texas State Securities Board,

208 E. 10th Street, 5th Floor, Austin, Texas 78701.

PART A: THE PERSON/FIRM SUBMITTING REPORT. Please provide your name, your title, and the name of your firm.

Please also include information that may be used to contact you or your firm in the event the Agency needs additional

information to fully review the information reported herein.

Your first and last name:

Your title:

Your firm’s name:

Your telephone number:

Your email address:

PART B: THE ELDERLY PERSON OR PERSON WITH A DISABILITY. Please provide the name of the elderly person or the

person with the disability, his or her address, his or her age and other relevant information.

Client’s first and last name:

Age:

Client’s address:

City:

State:

Zip:

Client’s telephone number:

Client’s email address:

Client’s date of birth:

Client’s sex:

Male

Female

Nature and extent of the

condition of the client:

Is another person responsible for the care of the client?

Yes

Unknown

If you answered “yes” in response to the previous question, please use the following field to provide the name and address

of the person responsible for the care of the victim.

Person’s first and last name:

Person’s address:

City:

State:

Zip:

Person’s telephone number:

Person’s email address:

Responsible person’s

relationship to the client:

PART C: THE PERSON ALLEGEDLY RESPONSIBLE FOR EXPLOITATION. Please provide the name of the person allegedly

responsible for the suspected financial exploitation, and any other relevant information about the person. Please also

provide the names of any additional persons allegedly involved in the suspected financial exploitation in the appropriate fields.

Suspect’s first and last name:

Suspect’s address:

City:

State:

Zip:

Suspect’s telephone number:

Suspect’s email address:

Suspect’s date of birth:

Suspect’s sex:

Male

Female

Suspect’s relationship victim:

Are any other parties suspected of engaging in the alleged financial exploitation?

Yes

If you answered “yes” in response to the previous question, use the following field to provide the name, address, telephone

number, email address and date of birth of other persons involved in the suspected financial exploitation. Please also provide

the name, address, telephone number and email address for any other entities involved in the suspected financial exploitation.

Information about any other persons and

entities suspected of financial exploitation:

PART D: BASIS OF THE REPORTER’S KNOWLEDGE AND OTHER RELEVANT INFORMATION. Please use the following field

to describe the suspect’s actions, his or her interactions with the elderly or disabled person identified as the victim, and his or her

interactions with personnel employed by your firm. Please provide as much detail as possible, including the dates of the alleged

conduct, the type of account subject to exploitation, and the nature of any harm to the client.

Did an agent, investment adviser representative or person serving in a supervisory or compliance capacity

for your firm alert your firm about the suspected financial exploitation described within this report?

Yes

If you answered “yes” in response to this

question, provide the person's name, his or her

telephone number and his or her email address.

Name:

Telephone:

Email:

Has your firm submitted or does your firm plan to submit the information contained within this report to

an agency other than the Texas State Securities Board and Texas Adult Protective Services?

Yes

If you answered “yes” in response to this item, please use the following field provide the name(s) of the agency(ies) have

received or will receive the information contained within this report, as well the point of contact ("POC") at the agency(ies).

POC’s email address:

Name(s) of agency(ies):

POC’s name:

POC’s telephone number:

Use this field to include the names

of any other agencies, and the names

of and contact information for their

points of contact.

The suspected financial exploitation occurred in connection with the following type(s) of account(s) maintained by the

victim at the reporting firm (select all that apply):

An individual or joint checking account

A 401(k) account or other defined contribution/benefit account

An individual or joint brokerage account

An IRA, Roth IRA, SEP-IRA or other retirement account

Other:

Did the suspected financial exploitation involve the client, suspect or third party successfully transferring

or withdrawing funds from an account maintained by the client at your firm?

Yes

If you answered “yes” in response to this question, use the following fields to provide more detail about the transfer of funds.

The financial exploitation involved the client or other party transferring funds from the client’s account to an

account maintained by the other party or a third party.

The financial exploitation involved the client or other party withdrawing funds from the client’s account.

The financial exploitation involved the client, suspect or third party transferring or withdrawing funds from the

client’s account, but the firm has credited the client’s account.

Other:

Has your firm: put a hold on the client’s account; restricted access to the client’s account; implemented

a strategy to ensure the account is subject to heighten security measures; or taken any other action to

protect the client’s funds?

Yes

If you answered “yes” in response to this question, please use the following field to describe the hold placed on the client’s

account, the means of restricting access to the client’s account, the strategy used to ensure the account is subject to

heightened security measures or any other action taken to protect the client’s funds.

Description:

Please use the following field to provide a narrative that describes the suspected financial exploitation. You should

draft the narrative using complete sentences, clearly explain the nature of the suspected financial exploitation and

describe any acts undertaken by the suspect to further the suspected financial exploitation. Your narrative should

also identify the basis of the reporter’s knowledge of the suspected financial exploitation. This narrative should

include a description of all available evidence of the suspected financial exploitation and summaries of

communications with the suspect, client, responsible person, or person reporting the incident. Your narrative

should also include any other information relevant to the suspected financial exploitation.