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ERIE.GOV | Your information resource from the government of Erie County, New York

Reporting Suspected Fraud

More Information:

Complaint Form

Please provide complete information to the best of your knowledge. Information that you enter here is held confidential until a case reaches a Court Hearing. You may remain anonymous by not including your personal information. However, we request that you include contact information so we may review or clarify information you have supplied.

Complete and submit by mail or electronically

Personal Information [Optional]

Name:

Address:

Address line 2:

City:

State:

Zip:

Telephone number [Day]:

Telephone number [Evening]:

Relationship to Recipient:

'Recipient in receipt of assistance'

Recipient Name:

Telephone number:

Case address:

Problem/s: check appropriate and fill in information

Actually lives at

Actually lives at (address):

Here since:

Landlord is:

Unreported person/s in Home

Unreported person/s:

Parent of child:

No

Yes

Which:

In home since:

Vehicle:

Employed

Employed at:

Hours:

Full Time

Part-time

Off Books

Hourly Salary: $ /Hour

Weekly Salary: $ /Week

Type of work:

Since:

Unreported income

Unreported income of:

Relationship to:

Employed at :

Hours:

Full Time

Part-time

Off Books

Hourly Salary: $ /Hour

Weekly Salary: $ /Week

Type of work:

Since:

Child Support for:

Other Income:

Unreported Resources

Unreported Resources:

Owns Vehicle

Color:

Year:

Make:

Model:

Owns property

Owns property at:

Gets Rent: $

Lawsuit Award

Lawsuit Award: $

Type:

Date:

Attorney:

Bank Accounts With:

Other information:

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Reporting Suspected Fraud

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