Public Assistance Fraud Referral Form
Overview
Subject
*
Your Information
I wish to remain anonymous
Please provide your phone number or email address in case we need more information.
First Name
*
Last Name
*
Agency
select an agency
Adult Protective Services
AIS Call Center
AIS Case Management
BPAI Call center
Child Care
CWS
DCSS
DHCS
Eligibility
Housing
IHSS
Probation
Public Authority
Other Agency
Email Address
*
Relationship
select relationship
Family Member
Friend
Neighbor
Gov Agency
Other Agency
Agency ID
Phone Number
*
Phone Number 2
Street Address
Apartment, suite, etc
City
State/Province
ZIP / Postal Code
Person You Are Reporting
First Name
*
Last Name
*
Street Address
Apartment, suite, etc
City
State/Province
ZIP / Postal Code
Date of Birth
Approximate Age
Social Security Number
Driver's License Number
Client ID Number
List Any Children Involved
Additional Persons or Organizations Involved
Programs (if known)
Suspected Fraud Details
What is the Suspected Fraud?
*
select an option from the list
Falsifying household composition and size
Purposely not reporting income and/or employment status
Residing outside the State of California
Other (describe)
Suspected Fraud Description
*
Other
Has this complaint already been submitted elsewhere?
*
No
Yes
If yes, to what person or agency? (Describe)
Attachments
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