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Reporter’s Contact Information
Providing your contact information is not required, but helpful in the event additional information is needed from you as the reporter.
Your contact information will remain confidential and not shared with anyone.
To remain anonymous, please do not complete this section.

• First Name:
• Last Name:

• Address:
• City:

• State: -Select- Missouri Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• Zip Code:

• County: -Select- Unknown ADAIR ANDREW ATCHISON AUDRAIN BARRY BARTON BATES BENTON BOLLINGER BOONE BUCHANAN BUTLER CALDWELL CALLAWAY CAMDEN CAPE GIRARDEAU CARROLL CARTER CASS CEDAR CHARITON CHRISTIAN CLARK CLAY CLINTON COLE COOPER CRAWFORD DADE DALLAS DAVIESS DEKALB DENT DOUGLAS DUNKLIN FRANKLIN GASCONADE GENTRY GREENE GRUNDY HARRISON HENRY HICKORY HOLT HOWARD HOWELL IRON JACKSON JASPER JEFFERSON JOHNSON KNOX LACLEDE LAFAYETTE LAWRENCE LEWIS LINCOLN LINN LIVINGSTON MACON MADISON MARIES MARION MCDONALD MERCER MILLER MISSISSIPPI MONITEAU MONROE MONTGOMERY MORGAN NEW MADRID NEWTON NODAWAY OREGON OSAGE OZARK PEMISCOT PERRY PETTIS PHELPS PIKE PLATTE POLK PULASKI PUTNAM RALLS RANDOLPH RAY REYNOLDS RIPLEY SALINE SCHUYLER SCOTLAND SCOTT SHANNON SHELBY ST. CHARLES ST. CLAIR ST. FRANCOIS ST. LOUIS CITY ST. LOUIS COUNTY STE. GENEVIEVE STODDARD STONE SULLIVAN TANEY TEXAS VERNON WARREN WASHINGTON WAYNE WEBSTER WORTH WRIGHT
• Phone:

• Email Address: *

Client Fraud Information
Please provide any known information as it relates to your concern about possible child care fraud.
This information is necessary in order to adequately investigate your allegation.

• *First Name: *
• *Last Name: *

• Sex: Male   Female
• Race: -Select- Unable to Determine White Black/African American Indian/Alaska Native Asian Hawaiian/Pacific Islander Multi-Racial

• DOB:
• Age:

• SSN:

• Address:
• *City: *

• *State: -Select- Missouri Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *
• Zip Code:

• County: -Select- Unknown ADAIR ANDREW ATCHISON AUDRAIN BARRY BARTON BATES BENTON BOLLINGER BOONE BUCHANAN BUTLER CALDWELL CALLAWAY CAMDEN CAPE GIRARDEAU CARROLL CARTER CASS CEDAR CHARITON CHRISTIAN CLARK CLAY CLINTON COLE COOPER CRAWFORD DADE DALLAS DAVIESS DEKALB DENT DOUGLAS DUNKLIN FRANKLIN GASCONADE GENTRY GREENE GRUNDY HARRISON HENRY HICKORY HOLT HOWARD HOWELL IRON JACKSON JASPER JEFFERSON JOHNSON KNOX LACLEDE LAFAYETTE LAWRENCE LEWIS LINCOLN LINN LIVINGSTON MACON MADISON MARIES MARION MCDONALD MERCER MILLER MISSISSIPPI MONITEAU MONROE MONTGOMERY MORGAN NEW MADRID NEWTON NODAWAY OREGON OSAGE OZARK PEMISCOT PERRY PETTIS PHELPS PIKE PLATTE POLK PULASKI PUTNAM RALLS RANDOLPH RAY REYNOLDS RIPLEY SALINE SCHUYLER SCOTLAND SCOTT SHANNON SHELBY ST. CHARLES ST. CLAIR ST. FRANCOIS ST. LOUIS CITY ST. LOUIS COUNTY STE. GENEVIEVE STODDARD STONE SULLIVAN TANEY TEXAS VERNON WARREN WASHINGTON WAYNE WEBSTER WORTH WRIGHT
• Phone:

• How did you learn about the suspected fraud?

•  

• *Explain in detail the nature of the alleged child care fraud:

• *  

• Check this box if you have support documents