RECIPIENT INFORMATION (Required)
INCIDENT INFORMATION (Required)
What is Electronic Theft?
- Skimming - the use of electronic equipment to take your benefits whithout your knowledge.
- Scamming is falsely convincing you to give your Link card/PIN and/or personal information to someone else who stole your benefits without having the physical Link card.
* Note that IDHS policy is that a compromised Link card that has been used in a theft transaction
MUST be replaced. You may get a replacement card at your local FCRC, or we will
be mailing a new Link card to your address on file.
PLEASE LIST THEFT TRANSACTION DETAILS BELOW (Required)
ADDITIONAL INFORMATION (Optional)
You may report additional information in this section. Additional information or a police report is not required but may be helpful in processing your claim.
If you filed a police report:
If you did NOT file a police report:
If you were instructed to call a number or go to a website, please provide that number and website information below.
YOUR SIGNATURE AND DECLARATION OF TRUTH ARE REQUIRED TO PROCESS THIS FORM
I attest that the information I have stated and provided in this form are true and accurate. By signing below,
I declare under penalty of perjury under the laws of the United States of America and the State of Illinois
that the information I have given on this form is true, correct and complete to the best of my knowledge.
I understand that if I knowingly give wrong information or leave out information that I know to be true and I
receive replacement benefits that I am not eligible for, I will be responsible for repayment, I can be
disqualified from receiving future benefits, I can be fined and I can be charged with a crime.