Public Assistance Fraud Recipient Complaint Form

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The Office of State Inspector General is strongly committed to identifying and eliminating fraud in assistance programs, such as cash assistance, food stamps, child care, home energy assistance, and medical assistance.

A complaint should be completed only if an individual has been issued benefits that you believe the individual was not entitled to receive. To ensure that your complaint is investigated thoroughly, please provide as much of the following information as possible.

Note: All fields with a red asterisk (*) must be completed for the complaint to be processed.

Please correct the following errors:

Recipient's First Name: Recipient's Last Name: Recipient's Address: City: State: Zip Code (5 digits): Date of Birth: Approximate Age (if DOB unknown): Recipient's Social Security Number (format: 123-45-6789): Recipient's Driver's License Number: Recipient's Children: Explain the Complaint:

The following information is optional. You may choose to remain anonymous, however, entering your contact information below allows the OIG to contact you in the event additional information is required regarding your tip.

Your Name: Your Address: Your City: Your State: Your Zip Code (5 digits): Your Telephone Number (format: 555-555-5555): Your Cell Phone (format: 555-555-5555): Your Email Address: