DSS: Client Fraud Reporting Form


Client Fraud Reporting Form


 

Reporting Fraud Committed by a Department of Social Services Client

 

We appreciate your interest in reporting fraud.  To report suspected fraud, you may either call the Department at 1-800-842-2155 or use the form below.  Use this form to report a client that you believe has fraudulently received assistance from programs administered by the State of Connecticut, Department of Social Services. This includes but is not limited to Temporary Family Assistance, Food Stamps, State Supplement for the Aged, Blind or Disabled, Medical Assistance and State Administered General Assistance.

 

Examples of situations that are fraudulent are: unreported income (either earned or unearned), hidden assets (bank accounts, property etc), unreported changes in household composition (either someone moved into the home or moved out), changes in shelter cost etc.

 

If you want to report fraud committed by a provider or vendor you should do so by following this link to the Provider/Vendor Fraud Reporting Form.

 

If you suspect or have knowledge of client fraud fill in the form below. You may then either print the form and fax or mail it to us, or you may submit the form electronically. Our address, fax and phone numbers appear at the bottom of this page. 

 

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.

 

Your name and phone number is optional but it would be helpful to us in case we need to contact you for additional or clarifying information.

 

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: 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:

 

 

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