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Note: Fields in RED must be completed.

CLIENT'S NAME:

CLIENT'S STREET ADDRESS:

CLIENT'S CITY:

CLIENT'S STATE:              CLIENT'S ZIP CODE:
Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming       
CLIENT'S DATE OF BIRTH:
/ /
CLIENT'S SOCIAL SECURITY NUMBER:
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Please enter ALL the information you have regarding the allegation or suspicion of how the client(s) is defrauding the department:

 

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YOUR PERSONAL INFORMATION:

YOUR NAME:

YOUR STREET ADDRESS:

YOUR CITY:

YOUR STATE:                      YOUR ZIP CODE:
Select State Not Specified Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming         
YOUR E-MAIL ADDRESS:

YOUR  AREA CODE + PHONE NUMBER:
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Note: Because of confidentiality laws we are NOT able to inform or respond to you as to the outcome or specifics of a case.