Reporting Fraud to the Arizona Department of Economic Security


(* Denotes Required Fields)
Subject(s) of Potential Fraud.
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
*Please include a detailed description as to why you believe this individual, provider, contractor or business might be involved in fraud or identity theft. Include the name(s) of all individuals and businesses involved, name(s) of additional witnesses, and describe any evidence you might have that supports your allegation. If you are reporting an individual whom you suspect of fraud, please provide as much information as you can about the suspect’s household members including their names, dates of birth (or approximate ages) and social security numbers.
Characters Remaining: 
 
Failure To Accept Suitable Work For Employers
If you are an employer who offered a job to someone who refused to accept the position, or a prior employee refused to return to work please provide details below, as the Department must investigate to determine if it was a bona fide offer. Please provide specifics of the job offered, including details about the position (pay rate, duties, hours, and start date), date job was offered, by whom and how it was communicated, and the reason the individual gave for refusing the job offer. If the offer was not a recall for the job in which the individual previously performed, describe the former working conditions. Read Additional Return to Work Guidance for Employers and Employees.
Characters Remaining: 
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
 


   

Due to strict confidentiality laws, the Department cannot confirm or deny an investigation initiated by the submission of this form nor can updates or outcomes be disclosed. We will review the necessary files and records in light of the information you have provided to determine the most appropriate action. If you provided information about yourself, you will be contacted again only if it is necessary to complete our investigation. Additionally, if you believe you were the victim of identity theft, we encourage you to go to the Federal Trade Commission (FTC) identity theft website, identitytheft.gov to report and protect yourself from further victimization. You are also advised to monitor your credit report for any other fraudulent activity that may come as a result of identity theft. Thank you for assisting in our efforts to combat fraud, waste, and abuse.