2. About the Report and Reporter
4. Reporter's Name
5. Remain Anonymous

   1. Yes
   2. No
7. May an investigator contact you for more information if necessary?

   1. Yes
   2. No
8. Phone Number
10. What is your relationship or connection with the client?
11. How long have you known the client?
13. About the Client
15. Client's Name*
16. Client's Date of Birth/Age
18. Client's Address
19. County
21. Client's Phone Number
22. Does the client have a spouse or significant other (SO)?

    1. Yes
    2. No
24. Spouse/SO's Name
25. Spouse/SO's Date of Birth/Age
27. Spouse/SO's Address
28. County
30. Other Spousal/CO Information
32. Does the client have children?

    1. Yes
    2. No
34. Children's Name(s) and Ages
36. Other Information on Children
38. Is the client employed?

    1. Yes
    2. No
39. Employer
40. How long with this employer?
42. Other Employment Information
44. About the Fraud Allegations
46. What is the nature of the allegation?*

    1. Selling FNS benefits/trafficking
    2. Misrepresenting household composition
    3. Underreporting income/exaggerating expense
    4. Living outside NC
48. Selling FNS benefits/trafficking
50. How long has this been occurring?
51. To whom is the client selling benefits?
53. Where is the sale taking place?
55. How do you know this information?
57. Misrepresenting household composition
59. How long has this been occurring?
60. Who is the client claiming/not claiming?
62. How do you know this information?
64. Underreporting income/exaggerating expense
66. How long has this been occurring?
67. What is the client reporting/not reporting?
69. How do you know this information?
71. Living outside NC
73. How long has this been occurring?
74. Where is the client living?
76. How do you know this information?
78. Is there anything else that you can thing of that might assist in the investigation?
80. Rowan County considers all reports of fraudulent activity important. Please contact us again if you have additional information.
Leave This Blank:


82. 1. Receive an email copy of this form.
83. Email address

    This field is not part of the form submission.

84. Submit

* indicates a required field