Public Assistance Fraud Report Form
Report suspected misuse of public assistance benefits by providing the details, people involved, time frame, location, and any supporting evidence.
Reporter Information
Full Name
*
First Name
Middle Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Report Details
Suspected Public Assistance Program
*
Please Select
SNAP
TANF
Medicaid
Housing Assistance
Unemployment Assistance
Other
Relationship to Subject
Please Select
Self
Family
Neighbor
Coworker
Service Provider
Other
Wish to Remain Anonymous
Yes
Jurisdiction or Location
*
Fraud Allegation Information
Name of person or household/business being reported
*
Suspected fraud description
*
Date range or approximate time period when the issue occurred
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Report
Should be Empty: