Special Assistance SA3410f4

Figure 4 - SUSPECTED FRAUD SUMMARY

SUMMARY OF FACTS

Name:

Date:

Address:

County Case #

Birthdate:

Case ID:

Children:

Employer:

CASE SITUATION:

ACT OF FRAUD:

EVIDENCE TO SUBSTANTIATE FRAUD AND INTENT TO FRAUD:

EVIDENCE TO SUBSTANTIATE AMOUNT OF INELIGIBLE ASSISTANCE RECEIVED:

BACKGROUND INFORMATION:

CLIENT INTERVIEW:

Date

Eligibility Analyst

For questions or clarification on any of the policy contained in these manuals, please contact your local county office.


Name:	Date:
Address:	County Case #
Birthdate:	Case ID:
Children:	Employer:

CASE SITUATION:




ACT OF FRAUD:




EVIDENCE TO SUBSTANTIATE FRAUD AND INTENT TO FRAUD:






EVIDENCE TO SUBSTANTIATE AMOUNT OF INELIGIBLE ASSISTANCE RECEIVED:




BACKGROUND INFORMATION:




CLIENT INTERVIEW:








Date		Eligibility Analyst