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2. Disclaimer

   Information submitted on this form will be sent via unsecured email. To protect sensitive information, do not enter the following items or similar information on this form: Social Security numbers, driver’s license numbers, bank account information, routing numbers, credit card numbers, medical information, passport numbers, and passwords. Please review our privacy policy located at www.jeffco.us/privacy. By submitting this form, you acknowledge and accept the terms listed in the privacy policy.

4. Your First Name
5. Your Last Name
7. Your Phone Number
8. Do you wish to remain anonymous?

   1. Yes
   2. No
10. Name of the person you are reporting*
    First and Last Name
12. Address of the person you are reporting
14. Address Line 2
16. City
17. State
18. Zip Code
19. Country
21. Names and ages of other people living with the person you are reporting.
    (significant other, children, other relatives, etc.)
23. Do you know the age or date of birth of the person you are reporting?
25. Do you know the Social Security Number of the person you are reporting?

    1. Yes

    1. No
27. Does the person you are reporting work? If so, do you know where?
29. Please tell us why you think they are committing Welfare Fraud:*
31. Any additional comments?
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field