Grand County Fraud Referral Form

Please use this form to submit a fraud referral to the Grand County Economic Security Assistance Unit. You may elect to remain anonymous if you choose. However, it will help the department conduct a more thorough investigation if they are able to contact you for additional information during the course of the investigation. Thank you.

What is your name?

May we contact you for further information regarding your referral?

Yes

No

If yes, what is the best method to contact you? (Check all that apply)

Email

Phone

Email Address

Phone Number

Referral Information

Please provide as much information you have for the person/people you are reporting. This information will help the office to locate and correctly identify the person/people being referred.

Name(s) of person/people you are reporting for Public Assistance fraud.*

Name(s) of additional person/people living in the home.

Physical address of household

Mailing address of household

Public Assistance programs you believe the household currently receives.*

Food Assistance, SNAP, Food Stamps Medicaid Colorado Works, TANF

Child Care Assistance, CCCAP Long Term Care Adult Financial, Old Age Pension, Aid to the Needy Disabled

Reason For Referral

Please indicate why you are referring this person/these people for Public Assistance fraud. It is not necessary to provide proof, the agency will conduct an investigation to verify any fraudulent activity. Any information you may have will be helpful to the investigation. Information MUST be provided in at least 1 of the following choices.

Failure to correctly report household members. Please specify.

Customer does not live in Grand County and/or Colorado. Please specify.

Failure to correctly report income of household members. Examples of income: earned income, self-employment income, alimony, child support, pension, etc. If possible, please specify type of income, source and amount.

Member of household is attempting or has sold benefits and/or given away their EBT card.
Please provide any information possible on when and where this occurred.

Other. Please provide any additional information that has not been previously disclosed.