Fraud Alert Form

Report Fraud, Waste and Abuse

Complete the form below including as many details as possible. To process your allegation correctly, it is important to provide explicit detail including who, what, when, where, why and how.

All submittals are encrypted and password protected for security. We treat all allegations in a confidential manner and will do our very best to safeguard your identity. You may remain anonymous by leaving blank the fields requesting personal information, however, this may preclude a thorough investigation of your allegation due to insufficient information.

If additional information is needed and you have given permission, a member of our staff will contact you. Otherwise, you should not expect any further communication from this office.

The fields marked with "«" are required. These fields must be completed in order to submit your form.

Tell Us About the Fraud, Waste or Abuse

Suspected Fraud, Waste or Abuse «

County Agency«

Name of Person (If known):

When did It Occur? :

Estimated $ Loss«

Description of Fraud, Waste or Abuse :«

How May We Contact You?

Specify below if we may contact you regarding your submittal. If yes, include specific instructions on how to contact you.

May we contact you if needed regarding your submittal« ?

YesNo

First Name

Last Name

Address

Address (Cont.)

City

State

Zip Code

Home Phone (Example: 4105556666)

Work Phone

Ext.

E-mail (Example: mail@mail.com)

Contact Instructions

Please include specific instruction on how to contact you. Indicate the best time that you can be reached and whether you would prefer to be contacted at home or at work. Because of the inherently unsecured nature of e-mail, it is not recommended to transmit sensitive or confidential information though e-mail.

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