DSS: Client Fraud Reporting Form


Client Fraud Reporting Form


 

REPORTING FRAUD IS EASY, SAFE AND SECURE

 

Note: Because of confidentiality laws we are NOT able to inform or respond to you as to the outcome or specifics of a case.

 

Use this form to submit online or follow this link to print this form and fax or mail it,

 

Note: The printed version of this form is in PDF format.  
If you do not have Adobe Acrobat Reader, you can download if FREE by clicking on this icon.

 

Providing your personal information is optional but is helpful in case we need to contact you for additional or clarifying information.  Reports can be made anonymously, and all reports are kept confidential. 

 

 

 

Note: Fields in RED must be completed.

CLIENT'S NAME:

CLIENT'S STREET ADDRESS:

CLIENT'S CITY:

CLIENT'S STATE:              CLIENT'S ZIP CODE:
      
CLIENT'S DATE OF BIRTH:
/ /
CLIENT'S SOCIAL SECURITY NUMBER:
- -

Please enter ALL the information you have regarding the allegation or suspicion of how the client(s) is defrauding the department:

 


YOUR PERSONAL INFORMATION:

YOUR NAME:

YOUR STREET ADDRESS:

YOUR CITY:

YOUR STATE:                      YOUR ZIP CODE:
        
YOUR E-MAIL ADDRESS:


YOUR 
AREA CODE + PHONE NUMBER:
()- -

 

Note: Because of confidentiality laws we are NOT able to inform or respond to you as to the outcome or specifics of a case.

 

 

State of Connecticut 
Department of Social Services
Investigations Division
55 Farmington Avenue
Hartford, Connecticut 06105-3730
Phone: 1-800-842-2155
Fax: (860) 424-4945

Email: clientfraud.dss@ct.gov