Request For Investigation - Suspected Calworks Stage 1 Child Care Fraud - Department Of Public Social Services
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1
2COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC SOCIAL SERVICES
REQUEST FOR INVESTIGATION – SUSPECTED CalWORKs STAGE 1 CHILD CARE FRAUD
Suspected child care fraud occurred while participant was receiving CalWORKs Stage 1 Child Care. If no,
STOP do not refer to WFP&I.
Early Fraud Telephone Referral (CHECK BOX)
Date of phone call: _____________________________
A. FROM
Agency Name
Agency Code
B. CASE INFORMATION
Parent/Guardian Name (Last, First)
Case Number
Language
Address (Number and Street)
(Apt. No.)
(City and State)
(Zip)
Telephone No.
C. PROVIDER INFORMATION
Provider Name (Last, First)
DMV License No.
Provider ID No.
Language
Address (Number and Street)
(Apt. No.)
(City and State)
(Zip)
Telephone No.
D. ELIGIBILITY INFORMATION
Current Child Care Eligibility Determination:
Adverse Action Initiated or Completed
Eligible Ineligible Questionable (Explain in “Remarks” below)
Child Care Amount Decreased
Child Care Terminated
Current Child Care Amount:
No Action taken (Status Pending)
Child Care is Correctly Determined Questionable (Explain in “Remarks”
below)
E. FRAUD INFORMATION
Type of Allegation:
Parent not Participating in WtW Activity Parent Not Employed No Child(ren) in the Home
Services Duplicated Misuse of Funds Other:
Name of Person Who Signed
Received
Services
Sex
Birthdate
SSN
DMV License No.
Male
Case Documents
During Fraud Period?
Yes No
Female
Name of Person Who Signed
Received
Services
Sex
Birthdate
SSN
DMV License No.
Male
Case Documents
During Fraud Period?
Yes No
Female
Date
of
Fact-Finding
Results of Fact-Finding Interview:
Parent Admitted Fraud Allegation Parent Denied Fraud Allegation
Interview
Parent Did Not Appear or Could Not be Contacted
F. REMARKS
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
G. STAFF SUBMITTING REFERRAL
Case Manager – Printed Name
File No.
Telephone/Extension
Date Completed
Supervisor/Manager – Printed Name
Title
Date Approved
H. FOR WFP&I USE ONLY – DO NOT WRITE IN THIS SPACE
Intake Input
Alert Code -
Allegation Code -
WFP&I Number -
T.O. Initials -
Date -
Assignment Input
Alert Code -
Allegation Code -
WFP&I Number -
T.O. Initials -
Date -
Statistical Data
Primary Aid Code -
Priority Code -
WFI Initials -
Date -
(Please Print – See Instructions on Reverse)
ST1-17 (rev. 06/22/05)
YELLOW: R&R/APP CONTROL COPY
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