Lake County Human Services Welfare Fraud Report Form
Do you suspect someone of providing information they know is false so they will receive assistance they are not eligible for?
What type(s) of fraud do you suspect this person is committing? Please select all that apply *
Required
Report Complaint Against
First and last name of the person you are reporting: *
Your answer
Address for the person you are reporting. Please include all other contact information you may have.
Your answer
Date of birth or age of the person you are reporting
Your answer
Social Security number for the person you are reporting
Your answer
Any other identifying information you may have on person you are reporting
Your answer
Any Other Adult Person Involved
First and last name of the person you are reporting:
Your answer
Date of birth or age of the person you are reporting
Your answer
Social Security number for the person you are reporting
Your answer
Relationship to person you are reporting
Your answer
Children in the household. Please include names and approximate ages if known.
Your answer
Household Income
Please list as much information as possible about income in the household. Include names, phone numbers and any other information
Employer(s) for adult household members.
Your answer
Other forms of income.
Your answer
Allegation
Describe how the client is committing welfare fraud. State when and where the welfare fraud was committed.
What is the Allegation?
Your answer
Complainant Information- Optional
You can remain anonymous but we would appreciate your name and phone number in case we have additional questions. Due to strict confidentiality laws, conclusions or details of an investigation will not be provided per Colorado Statute 26-1-114 and the Colorado Code of Regulation Volume IV-B-4010.52 and Volume III 3.604.3
May we Contact You?
If Yes, What is your contact information? Please include all forms of communication in which you prefer we reach you. Examples: phone number, mailing address, and or email address
Your answer
How to submit your complaint
You may select submit when this form is completed electronically or you may call (719) 486-4153 with questions or to provide information. You may also print and fax the completed form to (719) 486-4164 or mail to: Lake County Department of Human Services, Attn: Fraud Investigations, P.O. Box 884, Leadville, CO 80461
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms