Fraud Welfare Complaint Form - Human Services
To report Welfare Fraud via phone, call the WELFARE FRAUD HOTLINE at (877)-605-2321. To report suspected fraud outside of the County of San Bernardino call the : CALIFORNIA DEPARTMENT OF SOCIAL SERVICES FRAUD BUREAU at (800) 344-8477.
Welfare Fraud Report
San Bernardino County Human Services Program Integrity Division - All information is voluntary. Please fill out as much information as you can.
Person reporting Information (optional).
If more information needed is, how would you like to be contacted?
|First Name: |_____________________ |Last Name: |_____________________ |
|Phone Number: |_____________________ |
| | |
|Address: |_____________________ |City: |_____________________ |
|Zip code: |_____________________ |State: |_____________________ |
|Email Address: |_____________________ | | |
Who is the complaint against?
Information regarding complaint:
|First Name: |_____________________ |Last Name: |_____________________________ |
|Address: |_____________________ |DOB: | ________________ (mm/dd/yyyy) |
|City: |_____________________ |SS#: |_____________________ |
|Zip code: |_________ |Case number: |_____________________ |
| | | | |
|Gender: |_____________________ |
| | |
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What is your complaint about?
|Allegation: |________________________________________________________________ |
|What is your complaint |________________________________________________________________ |
| |________________________________________________________________ |
| |________________________________________________________________ |
| |________________________________________________________________ |
|To help us locate this person in our |________________________________________________________________ |
|files please type any additional |________________________________________________________________ |
|identifying information including: |________________________________________________________________ |
|children's names, ages, any employer,|________________________________________________________________ |
|school, father’s name, etc. |________________________________________________________________ |
| |________________________________________________________________ |
| |________________________________________________________________ |
| |________________________________________________________________ |
| |________________________________________________________________ |
| |________________________________________________________________ |
| |________________________________________________________________ |
| |________________________________________________________________ |
| |________________________________________________________________ |
| |________________________________________________________________ |
| |________________________________________________________________ |
| |________________________________________________________________ |
| |________________________________________________________________ |
| |________________________________________________________________ |
| |________________________________________________________________ |
Report by phone: (877) 605-2321
If you have hardcopy documents you would like to have included in the investigation you may:
Fax it to us at: 909-252-4359
Mail it to us at: SBCO Welfare Fraud, P.O. Box 1409 San Bernardino, CA 92408
Note: The additional documents may assist us in further processing your complaint. Please include a copy of the printable form. [pic]
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