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On-Line Welfare Fraud
Reporting
WELFARE FRAUD REFERRAL
 
Date: Reward Requested:
Yes No
Referred By: (Optional)
Telephone:
Address:

 

SUSPECT INFORMATION
Name:
Telephone:
Description:
Address:
Driver License/ID No.
Soc. Sec. No.
D.O.B
Known Aliases

FIRST ADDITIONAL SUSPECT(s) INFORMATION
Name:
Telephone:
Description:
Address:

 

SECOND ADDITIONAL SUSPECT(s) INFORMATION
Name:
Telephone:
Description:
Address:

 

VEHICLES OWNED/REGISTERED
Year: Make/Model: Lic.#:
Year: Make/Model: Lic.#:
Year: Make/Model: Lic.#:

 

BUSINESSES OWNED
# 1 Name: How Long?
   Address:
# 2 Name: How Long?
   Address:

 

PROPERTY OWNED
# 1 Address:
# 2 Address:
# 3 Address:

EMPLOYMENT
Name:
Address:
Name:
Address:
 
DESCRIBE NATURE OF THE FRAUD BEING COMMITTED
OR ANY OTHER HELPFUL INFORMATION:



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Last Updated May 2003