Other Fraud

Report Fraud

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Subject(s) of Allegation
Information about the person or business you are reporting.
*Last Name    *First Name    MI   DOB    SSN   
             
Street Address    City    State    Zip Code   
        
Telephone Number    Ext
 
 
Benefit Type

  Fraud





 
Witness(es)
*Do you know of other people who could provide information about this suspected fraud, waste or abuse?
 
Allegation Summary
If other adults or children live with the person you are reporting, please provide the names, dates of birth or approximate ages and Social Security Numbers, if you know them, for all household members.
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*Please provide detail information about the fraud.
FAILURE TO ACCEPT SUITABLE WORK FOR EMPLOYERS: If individuals refuse an offer of suitable work, theDepartment must investigate to determine if it was a bona fide offer. Please provide specifics of the job offered below:
1. Who offered the job and what date was it offered
2. What method was used to communicate the job offer to the individual.
3. Was the offer full time or part-time.
4. Start date.
5. Duties.
6. Rate of pay.
7. Days and Hours.
8. Was the individual being recalled to the same type of work previously performed? If not, describe the former working conditions.
9. What was the reason the individual gave for the refusal of the job offer
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Your Contact Information
If you provide your identity it could be subject to disclosure. You will be contacted only if additional information is required.
Last Name    First Name    MI   Email Address   
           
Street Address    City    State    Zip Code 
        
Telephone Number    Ext