Welfare Fraud Complaint Form

Date

Time

Reporting Party

First Name   Last Name

Address

City    State   ZIP

Phone  

Please Note: Confidentiality is ONLY guaranteed with anonymous callers

List Persons suspected of fraudulently collecting aid/include children in the home

Person’s Address

Address

City    State   ZIP

Is this person working? Yes No

Company's Name  

Position Held  

Address

City    State   ZIP

Work Phone #  

Vehicle used by Person(s):

(1)  (License Plate #)

(2)  (License Plate #)

Summary of Complaint

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