Program Violations and/or Fraud Reporting Form
Housing Authority of the County of Santa Cruz
Program Integrity Office
2931 Mission Street, Santa Cruz, CA 95061
Phone: 831-454-9455 ext: 251
Please submit this form by mail to the address above or electronically by e-mail.
Please give as much information and as many details as possible. If necessary, print and use the back of this form.
Name of the person(s) committing violation and/or fraud: _____________________________________________
At what address? _____________________________________________________________________________
What appears to be a violation and/or fraud? (Check all that Apply)
Unreported Income. How much and from where: _______________________________________________
Additional People Living in the Home.
Name(s): ____________________________________________________________________________
Age(s): __________________________ Since When: __________________________________
Vehicle description: ____________________________________________________________________
Someone Moved Out of the Home.
Name: ________________________________________ Date: _____________________
Drugs and/or Criminal Activity.
Who: ________________________________________________________________________________
What and when? _______________________________________________________________________
Police Reports? ___________________________ Currently Incarcerated? ___________________
Subleasing of the Home.
To whom: ___________________________________________________________________________
How much rent is being charged and since when? ____________________________________________
Landlord is Accepting Additional Rent.
How much and since when? ______________________________________________________________
Landlord is a Relative.
Name of landlord: _______________________ What is the relationship? _____________________
Other Violations or Fraud (charging live-in aide rent, landlord living in the home, etc):
_____________________________________________________________________________________
_____________________________________________________________________________________
Who, other than you, can confirm the violation and/or fraud:
Name: _____________________________________ Contact Phone Number: ___________________
Name: _____________________________________ Contact Phone Number: ___________________
OPTIONAL - Confidential Information.
Giving your name and contact information is optional, however, we may need to ask you for more details and
may not be able to complete the investigation if we cannot reach you. Your name and contact information will be
kept confidential (please see Confidentiality
on our Program Violations and Fraud web site page for details):
Your name: _______________________________ Phone number: _______________________
E-mail address: ____________________________ Date: _______________________
01/14/10 120176 MJ
