Public Assistance Fraud Referral Form

Referred By:

Do you wish to remain anonymous?
Fraud (check programs)

Suspect/person you are reporting Information

Examples: If they are working please tell us where they are working. If absent parent is living in home, please provide name. If Child no longer residing in household, state which child If Client has unreported income, state where it’s from, if known Fraudulent use of EBT card