Suspected Fraud Reporting Form

It is important to report suspected fraud to ensure that County tax dollars are being used for their intended reason, which is to help those in need.  By reporting suspected fraud, we ensure that there will be sufficient benefits available to help our friends and family should they ever be in need of assistance.  This is one of the most direct ways where each and every citizen can make a difference.

To learn more about what will happen to the information you provide, please click here. 

Optional information to be completed by the reporter.

First Name:            Last Name:       
Street Address:       
City:    State:             Zip:      
                                                                                                             
Phone No:  Alternate Phone:     Email:   

 (Although the above information is not required, having your contact information will expedite the investigation if we should need additional information.)
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Name of Person Receiving Assistance (Required)

First Name:           Last Name       
   SS#:              (No Dashes)  Date of Birth:          (Example:  02/09/1967)
Address of Person Receiving Assistance:
Street Address:       
City:           State:             Zip:             

What would you like to report?  (Please check all that apply.) 
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1. Recipient or person in the household is working? "On the Books"    "Off the Books"
     Name of person employed:  First:    Last:
     Name of Employer: 
     Address of Employer:  Street Address:
City:    State:      Zip:     

 
2.  Recipient is not employed where they reported. Are they working somewhere else?    Yes   No
      Name of Employer:  Name:   
     Address of Employer:  Street Address:
City:    State:      Zip:    


3.  There is an unreported person living in the home. Name of person(s) First Name:    Last Name:
                                     First Name:    Last Name:
                                     First Name:    Last Name:
      How long has the person been living in the home? 
            Less than 12  months: 
            From 12 months to 24 months:  
            Over 24 months: 
      Is this person the parent of a child in the home?  Yes   No
      Name of children    First Name:    Last Name:
                                     First Name:    Last Name:
                                     First Name:    Last Name:

     
 4.  The recipient's children are no longer in the home.  When did he/she move?   1st Child       Date: (Example 01/15/2006)
            Where are they currently living?  Street Address:
City:    State:      Zip:    

2nd child      Date: (Example 01/15/2006)
            Where are they currently living?  Street Address:
City:    State:      Zip:    

3rd child   Date: (Example 01/15/2006)
            Where are they currently living?  Street Address:
City:    State:      Zip:    
 


5. Recipient owns the following: Vehicle:  Year:    Make:   
                Model:    Color:  
                License Plate #:  

      Bank Account:  Name of Bank:   
      City:   State:      Zip:    
If more space is needed, please complete in the additional info area below. 
(Example:  a boat, stocks or bonds.)


 
 



6.  The recipient is receiving child support from the absent parent. What is the absent parent's name:   First:    Last:
              How much is He/She receiving?  $    Per


7.  The recipient does not live where he/she says he/she is living. New Street Address:
City:    State:      Zip:    
When did they start living there?  Month:     Year:  


 8. Please include any additional information that you would like to share below