SSA Public Fraud Reporting Form

Fraud Reporting Form Need Larger Text?

Please use this form to report allegations regarding violations of law or regulations affecting Social Security Administration programs.

Section I Person or Business Reporting Fraud (Optional) Form Help

NOTE: Please keep in mind that if you choose to remain anonymous, the absence of your contact information may limit our ability to conduct a complete investigation.
E-mail address for an acknowledgement of your complaint
Are you filing as a Private Individual or on behalf of a Business? Private Individual Business
Section I-A - YOUR INFORMATION
	Last Name
	First Name
	Middle Name / Initial
	Home Address
	City
	State
	Zip Code
	Home Phone
	Cell Phone
	Work Phone	Ext.
	Social Security Number
	Are you a victim of the alleged violation/fraud?	Yes No

Section I-B - YOUR BUSINESS INFORMATION (Skip this section if you completed Section I-A)
	Business Name
	Employer Identification Number
	Business Address
	City
	State
	Zip Code
	Business Phone
	Business Cell Phone
Section II Person Committing Fraud TOP of FORM
Are you reporting a Private Individual or a Business? Private Individual Business
Section II-A - Reporting a PRIVATE INDIVIDUAL If you are reporting more than one individual, please add your information in the Summary Section below.
	Last Name
	First Name
	Middle Name / Initial
	Alias
	Social Security Number
	Address
	City
	State
	Zip Code
	Home Phone
	Cell Phone
	Work Phone	Ext.
	Date of Birth	(MMDDYYYY)
	Sex
	Race
	State of Birth

Section II-B - Reporting a BUSINESS (Skip this section if you completed Section II-A) If you are reporting more than one business, please add your information in the Summary Section below.
	Business Name
	Employer Identification Number
	Business Address
	City
	State
	Zip Code
	Business Phone
	Business Cell Phone
Section III Primary Victim Information If you are reporting more than one victim, please add your information in the Summary Section below. TOP of FORM
	Last Name
	First Name
	Middle Name / Initial
	Address
	City
	State
	Zip Code
	Social Security Number
	Home Phone
	Cell Phone
	Work Phone	Ext.
Provide the following items if they apply:
	Date of Birth	(MMDDYYYY)
	Sex
	Race
Section IV Summary TOP of FORM
	Description - Please furnish the facts of the alleged fraud. Include who, what, when, where, how and why. Your description is limited to 4000 characters.

Message: If you do not enter this allegation in a timely fashion, you will be timed-out in 60 minutes,
lose your data and will be re-routed to the Public Fraud Reporting Home Page. Do not bookmark this page.


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	Last reviewed or modified Thursday Mar 06, 2008