Fraud Allegation Form | Office of Management and Budget

First name of person suspected

Last name of person suspected

DOB of person suspected

Phone number of person suspected

Case # of person suspected (if available)

Address of person suspected

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Are there additional people involved in the allegation?

Yes

Name of Additional Person Involved

First

Last

If yes, please enter the first and last name of the additional individual.

Category of Fraud, Waste or Abuse

Supplemental Nutrition Assistance Program (SNAP)

Child Care Assistance Program (CCAP)

Rhode Island Works (RIW)

Medical Assistance (MA)

Low Income Home Energy Assistance Program (LIHEAP)

Other Benefit Program

State Funds/Resources

Additional Details of Fraud, Waste, or Abuse

Unreported Income

Misuse of Public Benefits

People living in house does not match list of people reported on application

Person moved out of state

Identity fraud

Person has secondary insurance (medical allegations only)

Childcare provider improperly received childcare assistance payments

If you selected the "Other Benefit Program" or "State Funds/Resources" above, please enter the name of the program or impacted state agency.

Details of misconduct

Contact Information

Please provide your phone number or email in case we need to contact you. PLEASE NOTE: Supplying your name and contact information will enable us to contact you with additional information that may be needed to properly investigate your allegation. We will not share this information. Your information is not required, this report can remain anonymous*.

Name of reporter (Optional)

Phone number of reporter (Optional)

Email of reporter (Optional)

Are you willing to be interviewed further?

Yes

Do you have supporting documentation/evidence of your allegation?

Yes

Upload a supporting documentation/evidence of your allegation

One file only.
10 MB limit.
Allowed types: gif, jpg, jpeg, png, pdf, doc, docx, .

* Anonymous allegations cannot always be investigated if enough information is not provided. If not anonymous, confidentiality of your identity will be maintained as much as possible during any investigation but cannot be fully guaranteed. There is a possibility if you are not anonymous that you may be requested to testify at any trial that might occur as a result of this allegation.

CAPTCHA

What code is in the image?

Enter the characters shown in the image.

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.