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Nassau County On Line Fraud Report Form

For Residents of Nassau County, NY

Please complete this form with as much information and in as detailed a manner as possible

1. Complaining Party

Do you wish to remain anonymous? (if yes skip to section 2)

Name 
 
Address 
 
City 
 
State 
 
Zip 
 
Phone 
 
Alt Phone
 
Email 
 

2. Fraud Information

A. Type of Fraud





Other -

 

Complaint Against

B. Recipient of Benefits
Name
 
DOB or Age
 
Address
 
City
 
State
 
Zip
 
Phone
 
C. Provider of Services
Providers Name
 
Providers ID Number
 
Address
 
City
 
State
 
Zip
 
Phone
 
Location of Fraudulent Activity
(if different from providers address)
 
Insurance Claim Number
 

3. Description of the suspected fraudulent activity or misuse of public funds.

Give a statement that clearly describes the persons involved, dates, locations and nature of the incident or issues that you are reporting. The More specific the information you provide us, the better we will be able to follow-up on your complaint

*Have you contacted your local law enforcement agency with regard to this Complaint?

If yes, what is the name of the agency and when did you contact that agency?

*Have you contacted any other local or state agency with regard to this Complaint?

If yes, what is the name of the agency and when did you contact that agency?

 

*By submitting this form, I confirm that I understand that The Nassau County Department of Social Services does not represent private citizens seeking the return of money or other personal remedies.

*Due to laws regarding client confidentiality, The Department of Social Services is prohibited from disclosing the outcome of an investigation. 

*The sources of all fraud referrals are kept strictly confidential. 

THANK YOU FOR TAKING THE TIME
TO REPORT PUBLIC BENEFITS FRAUD