Public Assistance Fraud Referral Form

Overview

Subject *

Your Information

I wish to remain anonymousPlease provide your phone number or email address in case we need more information.

First Name *

Last Name *

Agency

Email Address *

Relationship

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? *

Suspected Fraud Description *

Other

Has this complaint already been submitted elsewhere? *NoYes

If yes, to what person or agency? (Describe)

Attachments

Please provide a description of the attachments.

Attach a file

Imperial County

District Attorney's Office

Overview

Your Information

Person You Are Reporting

Suspected Fraud Details

Attachments