Suspected Fraud/criminal Activity Complaint Form (Page 2 of 2) in pdf

Suspected Fraud/Criminal Activity Complaint Form

If the complaint is about unreported income, please let us know any information regarding the amount or

source of income:

_________________________________________________________________________________________

If the complaint is about drug or criminal activity, please complete the following if known:

Who is involved? Tenant [] Landlord/Owner []

Have the police been involved? Yes [] No [] If yes, how?___________________________________________

Have any arrests been made? Yes [] No [] If yes, who?_____________________________________________

Do you know the officer name or agency (i.e., Winnebago County Sheriff, Rockford Police)?

_________________________________________________________________________________________

Is there any other information you believe would be helpful regarding your allegations? (e.g., bank accounts,

store/credit card accounts, school records, court documents, police case numbers, child protective service or

other government --involvement, property information)

__________________________________________________________________________________________

REQUEST FOR NON-DISCLOSURE: Pursuant to RCW 42.56.240(2) of the Public Records Act, I request that

information revealing my identity NOT be disclosed because I fear disclosure would endanger my or someone

else’s life, physical safety, or property. SIGN HERE:________________________________________________

Mail/Email/Fax form to:

Laura Snyder

Director of Housing Operations

Rockford Housing Authority

223 S. Winnebago St.

Rockford, IL 61102

FAX: 815-489-8555

Email:

[] Fraud hotline call

[] Complaint form mailed, dropped off or faxed to RHA offices

[] Other: _________________________________________

________________________________________________

____________________________________________

RHA Employee Signature and Date

Date Received

OK to release reporting person’s name?

[] YES []NO [] Did not specify

Suspected Fraud/criminal Activity Complaint Form Page 2