First Name:
Last Name:
Mailing Address:
City, State, ZIP:
Phone:
Alternative Phone:
Email:
Would you like to remain anonymous: Yes No
What is your preferred language to communicate: English Spanish Polish Arabic Russian Mandarin/Cantonese
Subject First Name: *
Subject Last Name: *
Do you know the subject's address: Yes No
Subject Address:
Subject City, State, ZIP:
Subject Phone:
Subject Email:
Do you know the subject's date of birth or age: Yes No
Subject Birth Date:
Subject Age:
Do you know the last 4 digits of the subject's social security number: Yes No
Last 4 digits of subject's social security number:
Do you know the subject's employer: Yes No
Subject Employer Name:
Subject Employer Address:
Subject Employer City, State, ZIP:
Subject Employer Phone:
Subject Employer Email:
Do you know other members who live in the household: Yes No
Other household member First Name:
Other household member Last Name:
Other houshold member relationship to subject: Child Spouse Significant Other Parent Guardian Other
Is this individual employed: Yes No
Other Member Employer Name:
Other Member Employer Address:
Other Member Employer City, State, ZIP:
Allegation (please provide as much detail as possible including other forms of income not listed above): *
Do you know if anyone in the household might present safety concerns to an Investigator (i.e. weapons, dangerous drugs, vicious animals, gang activity, etc.): * Yes No
Explain safety concerns: *
Thank you for the report of possible fraud to the Illinois Department of Human Services, SNAP Fraud Unit. You may be contacted by a department representative if further information is needed.
Illinois Department of Human ServicesJB Pritzker, Governor · Dulce M. Quintero, Secretary Designate
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