INVESTIGATIONS AND RECOVERY

CONCERNED CITIZENS REPORT

Use this form to report a client that has received benefits or has applied for benefits that you believe he/she is not entitled to. Examples of situations that may be considered fraudulent are: unreported income (working, gambling winnings, court settlements), hidden assets (such as bank accounts, property, etc.), unreported household changes (someone moved in/out), unreported changes in expenses (rent decrease), etc.
 

Your name and phone number is optional and will be kept confidential, but it would be helpful to us in case we need to contact you for additional or clarifying information. May we contact you via e-mail?
Yes   No

YOUR PERSONAL INFORMATION:
Your Name:
Your Address:
City, State:
Your E-Mail Address:
Your Area Code & Phone No:
WHO IS THE COMPLAINT AGAINST?
Client's Name:
Client's Address:
Client's City/State:
Date of Birth:    or Approximate Age: 
Social Security # (If known):
DESCRIBE THE CLIENTS VEHICLE(S):
 
License plate number(s)?:
ADDITIONAL INFORMATION REGARDING THE CLIENT:

Who is living with the client?
Relationship?
Does anyone in this household work?    Yes    No    Don't Know

If the client or someone else in the household is employed, please provide the following information:

Name of person working:
Employer's Name:
Employer's Phone Number:
Employer's Address:
Employer's City, State:

Does anyone in the household have other unreported income (such as child support, unemployment benefits, disability benefits, etc.)?
Yes   No   Don't Know
 

Who?:
Type of Income?:
What is the monthly amount received?:
Received From?:

Does anyone in the household have unreported resources (such as bank accounts, vehicles, property, etc.)?  
Yes   No   Don't Know
 

Who?:

 
What type of resource? If resource is a vehicle, please describe and provide license plate number if known:

CHILD OR CHILDREN'S INFORMATION:
Child/ren's Name:
Date of Birth or Age:
Social Security No. (if known):
DESCRIBE THE SITUATION OR ACTIONS BY THE CLIENT YOU BELIEVE TO BE INAPPROPRIATE OR ILLEGAL:
APPROXIMATE DATE IT OCCURRED (EX: MARCH 2003 TO DECEMBER 2003):
ADDITIONAL INFORMATION YOU WOULD LIKE TO ADD:

      

NOTE: BECAUSE OF CONFIDENTIALITY LAWS WE ARE NOT ABLE TO INFORM OR RESPOND TO YOU AS TO THE OUTCOME OR SPECIFICS OF A CASE.