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.
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

* indicates a required field