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2. Tips reported using this form are untraceable as to source/sender. Tips reported using this form do not leave an audit trail - electronic or otherwise - back to sender, sender's terminal or UserI D. Once tips are printed, the electronic copy is then deleted and purged from the system.
   
   Please include as much detailed information as possible in your fraud tip. Vague allegations may not be able to be substantiated.
4. Name(s) of Person(s) Suspected of Committing Fraud / Abuse:*
5. Area Where Suspected Fraud / Abuse Is Occurring:*
7. Date(s) and/or Duration of Occurrence(s):*
   Date(s) and/or Duration of Occurrence(s): Start Date

   Date(s) and/or Duration of Occurrence(s): Start Time

   —

   Date(s) and/or Duration of Occurrence(s): End Date

   Date(s) and/or Duration of Occurrence(s): End Time
9. Approximate Dollar Amount / Value Involved:*
10. Name(s) of Any Other Witnesses:
12. What is the potential fraud or against what County agency is the potential fraud committed?*
16. May We Contact You?*

    1. Yes
    2. No
18. First Name
19. Phone
21. Last Name
22. Email Address
24. Address1
26. City
27. State
28. Zip
Leave This Blank:


30. Submit

* indicates a required field