Online Welfare Fraud Reporting Form

Welfare Fraud Reporting Form

Your contact information is kept confidential, however an investigator may contact you for additional information if needed.

Your Name:

Your Email Address:

Your Phone Number:

Your Address:

Participant's Name:

Participant's Phone Number:

Participant's Address:

Participant's Date of Birth (or Approximate Age):

Who is living in the participant's household?:

Is anyone in the household working? If so, who is working and where?:

Name of Participant's Spouse/Significant Other:

Spouse's Date of Birth (or Approximate Age):

Participant's Social Security Number:

Participant's Client ID Number:

Programs:
Cash AssistanceChild CareFood StampsMedical

Participant's Children (Name, Age, Client ID #):

Complaint: