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 Reporting Fraud (Optional) Form Help

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

Section II Person Committing Fraud TOP of FORM
	Last Name
	First Name
	Middle Name / Initial
	Alias
	Social Security Number
	E-mail Address
	Business Name
	Employer Identification Number
	Address
	City
	State
	Home Phone
	Cell Phone
	Work Phone	Ext.
	Date of Birth	(MMDDYYYY)
	Sex
	Race
	State of Birth

Section III Primary Victim Information TOP of FORM
	Last Name
	First Name
	Middle Name / Initial
	Social Security Number
	Home Phone
	Cell Phone
	Work Phone	Ext.
	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 50 lines.

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 Wednesday Apr 01, 2009