State Plan Fraud Form

The Great Seal of the State of New Jersey
Claimant Information

To report fraudulent activity, please complete the form below. In order to assist with our investigation, supply all the information that is known to you.

**
(First, Middle, Last)
Name of the claimant
**
(Street)
(Address Line 2)
(City, State, Zip as nnnnn-nnnn or nnnnn)
Address of the claimant
**
Comments explaining fraudulent activity

(** indicates a required field)

Page 1 of 1