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Please provide the name and address of the individual(s) who are alleged to have committed fraud:

Name(s)(*)

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Address(*)

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Please provide the specific events and evidence, or loss to HUD program. Include any scheme you believe was used to perpetrate the alleged fraud:

Describe evidence(*)

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[Include any documentation to support the allegation(s). Information that is too vague or cannot be supported can result in a closed report with no action taken.]

Please provide the date (include time and frequency if possible) of the specific event(s):

Date(*)

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Why do you believe this event occurred?(*)

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Your name and contact information is completely voluntary – it’s not required to make a report. However, it may be beneficial to do so in case the PHA has additional questions.

Your Name

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Your Address

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Phone number

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Alternate Phone Number

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Prove you're human(*)

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