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LT/ELDER ABUSE TO BE COMPLETED BY REPORTING PARTY. PLEASE PRINT OR TYPE. SEE GENERAL INSTRUCTIONS. A. VICTIM Check box if victim consents to disclosure of information Ombudsman use only - WIC 15636(a) *NAME (LAST NAME FIRST) *AGE DATE OF BIRTH GENDER SSN M LANGUAGE ( CHECK ONE) NON-VERBAL ENGLISH OTHER (SPECIFY) *TELEPHONE ETHNICITY F *ADDRESS (IF FACILITY, INCLUDE NAME AND NOTIFY OMBUDSMAN) *CITY *ZIP CODE *PRESENT LOCATION (IF DIFFERENT FROM ABOVE) *.

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