Form Center

2. Complaint Form Please complete this form to report suspected fraud or abuse. Answer the questions as completely as possible. Vague allegations may not be able to be substantiated. Please be as specific as possible. If you wish, you can supply information so that we may contact you, or you can remain anonymous. All information submitted will remain confidential.
4. Name(s) of Person(s) Suspected of Committing Fraud / Abuse:*
5. Area Where Suspected Fraud / Abuse Is Occurring:*
7. Date(s) and/or Duration of Occurrence(s):*
   Date(s) and/or Duration of Occurrence(s):* Start Date

   Date(s) and/or Duration of Occurrence(s):* Start Time

   —

   Date(s) and/or Duration of Occurrence(s):* End Date

   Date(s) and/or Duration of Occurrence(s):* End Time
9. Approximate Dollar Amount / Value Involved:*
10. Name(s) of Any Other Witnesses:
12. What is the potential fraud or against what County agency is the potential fraud committed?*
14. Relevant Documents:
22. May We Contact You?

    1. Yes
    2. No
24. First Name
25. Last Name
27. Phone Number
28. Email Address
30. Address1
32. City
33. State
34. Zip
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field