Fraud Allegation Form Current Type of Fraud Details Complete Submitting the same referral multiple times will not expedite the processWe are currently processing all referrals in the order in which they are received We kindly ask for your patience as we work through each submission with care and attention. Are you reporting any of these circumstances? Providing False or Misleading Information to obtain state benefits Failing to Report Changes while obtaining state benefits Receive benefits from multiple states or programs simultaneously Selling or Misuse of state benefits Are you reporting any of these entities? Someone stole my/someone else's state benefits Child Care or Health Care Provider Misconduct Store or State Vendor Misconduct State Agency or Employee Misconduct Something else (We’ll get you to the right place) You can also report to our hotline (401) 574-8175 but it will take us longer to process it. Please do not submit the same referral to both the hotline and web form or submit the same referral more than once, this will delay the review of your referral. Is your complaint related to the following state benefit(s)? Is your complaint related to the following state benefit(s)? Select one or more program(s) you are reporting: Food Stamp (SNAP) Cash Assistance (RI Works/GPA) Child Care Assistance (CCAP) Energy Assistance (LIHEAP) Medical Assistance (Medicaid) Not listed Providing False or Misleading Information to obtain state benefits Providing False or Misleading Information to obtain state benefits Select 1 or more of the following: Someone used my or others information to apply for state benefits Misrepresenting household size Falsifying or omitting income or employment status Using false identities or Social Security numbers Concealing assets or property ownership Do you know who? Yes No Failing to Report Changes while obtaining state benefits What changes were not reported? Changes in household members New employment or income sources Relocation to a different state Receipt of other public assistance benefits Household member deceased or incarcerated Receiving benefits from multiple states or programs simultaneously State / Program If you could, please list them States AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Programs - Select -Food Stamp (SNAP)Cash Assistance (RI Works/GPA)Child Care Assistance (CCAP)Energy Assistance (LIHEAP)Medical Assistance (Medicaid) Do you know if they use the same or different (possible stolen) identities to obtain benefits for multiple state / programs Same Identity Different Identities Buying/Selling or Misuse of state benefits Please identify the fraud scheme Buying/Selling/Trading benefits for cash/goods/services Unauthorized individuals using EBT cards Purchasing non-eligible items with benefits Is the card holder using any of the following cards of Deceased Incarcerated Elderly/Disabled None of above Child Care or Health Care Provider Misconduct Who are you reporting? Child Care Provider Health Care Provider Someone stole my/someone else state benefits Who are you reporting? (I think) I know who stole the benefits I don’t know who stole the benefits Store or State Vendor Misconduct Who are you reporting? Store State Vendor (Group Homes, Contractors, etc..) State Agency or Employee Misconduct Who are you reporting? State Agency State Employee Leave this field blank