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: |_____________________ |

|  |  |

[pic]

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]

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download