Benefits Fraud Report Form

2. Report Your Concerns
   Please complete this form or call our fraud hotline at 303-636-1835 if you suspect that someone you know is falsifying information to qualify for assistance benefits, or is committing fraud in the use of benefits from a Human Services Department program. Provide as much information as possible.

   Please complete this form or call our fraud hotline at 303-636-1835 if you suspect that someone you know is falsifying information to qualify for assistance benefits, or is committing fraud in the use of benefits from a Human Services Department program. Provide as much information as possible.

4. Today's Date*
   Today's Date

5. Would you like to report anonymously?*

   1. Yes

   1. No

   You have the option to remain anonymous, but providing your name and phone number may help with the investigation.

7. Your Name

8. Your Phone Number

10. Information on Individual Suspected of Fraud

12. First Name

13. Last Name

14. Social Security Number

16. Address

18. City

19. State

20. Zip

22. Date of Birth
    Date of Birth

23. Phone Number

25. What program(s) do you suspect this person is violating?*

    1. Medicaid
    2. Food Assistance
    3. Child Care Assistance

    1. Cash Assistance (Colorado Works/TANF, Adult Financial, etc)
    2. Child Support
    3. Other - Please explain below

27. If other program, please describe:

29. What type(s) of fraud do you suspect this person is committing?*

    1. Not reporting the correct number of individuals in the home
    2. Receiving benefits in more than one state
    3. Not reporting income (earned/unearned)
    4. Falsifying documents (ie. leases, check stubs, identification)
    5. Other - Please explain below

31. If other fraud, please describe:

33. Please provide a detailed description of the suspected fraudulent actions. *

Leave This Blank:


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

    This field is not part of the form submission.

37. Submit Submit and Print

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