Report suspected state program fraud

Report suspected state program fraud
Executive Order 25-01 and Executive Order 25-10 require Minnesota state agencies and employees to report suspected state program fraud and financial crimes to the Minnesota Bureau of Criminal Apprehension’s (BCA) Financial Crime and Fraud Section (FCFS), Minnesota Management and Budget (MMB), the Minnesota Department of Administration (Admin), Minnesota Department of Revenue (MDOR), and the Office of the Legislative Auditor (OLA). Use this form to provide information to the BCA FCFS, MMB, Admin and MDOR.
If you are a whistleblower reporting suspected state program fraud (see whistleblower definition above) your information will only be sent to the BCA FCFS and will not be sent to MMB, Admin or MDOR in keeping with whistleblower protections in Minnesota law.
Are you a whistleblower?*

YesNo
Select the state agency involved in this submission*
If other, enter state agency involved
Reporting party contact information and anonymous reporting party disclaimer
Enter information about yourself (the reporting party)
Name

First NameLast Name
Email
example@example.com
Phone number
Please enter a valid phone number.
Organization for which you work
No personally identifiable information is required to submit an allegation of known or suspected fraud. However, choosing not to provide contact information may inhibit successful investigation of the allegations.

Individuals reporting fraud may fall under Minnesota's Whistleblower Act.
I am reporting (select one or more of the following)*
What agency is being impacted*
Is this a Medicaid funded or supported program?*

YesNo
Program name(s)
If other, enter impacted agency
Origin of funding?

StateFederal
Do you have information about the suspect*

YesNo
Suspect Information
Name

First NameLast Name
Date of birth

MonthDayYear
Date
Social security number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Please fill in all known information about the suspect’s place of employment
Location
Occupation/Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Suspect's work phone number
Please enter a valid phone number.
Other Identifying features (such as scars, marks or tattoos)
Any known tax issues?

YesNo
Please fill in all known information about the suspect’s vehicle
Plate
Make
Model
Color
Other identifying features on the vehicle (bumper stickers, damage, tinted windows)
Do you want to provide information about another suspect

YesNo
Suspect information
Name

First NameLast Name
Date of birth

MonthDayYear
Date
Social security number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Please fill in all known information about the suspect’s place of employment
Location
Occupation/Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Suspect's work phone number
Please enter a valid phone number.
Other Identifying features (such as scars, marks or tattoos)
Please fill in all known information about the suspect’s vehicle
Plate
Make
Model
Color
Other identifying features on the vehicle (bumper stickers, damage, tinted windows)
Loss information
Is the suspected fraud activity still happening?

YesNo
Timeframe over which the fraud has occurred or duration of the fraud activity
Select one of the two options below

Financial loss has occurredFraud was attempted but no financial loss occurred
If financial loss occurred, please provide as much information below as is known
Loss amount
Have any lost funds been recovered?

YesNo
How much was recovered?
Suspect Financial/Banking Institution Information
Financial/Banking institution name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Reporting
Has this been reported to another agency

YesNo
Please fill out the fields below
Other agency information was reported to
Case or incident number
Agency contact name
Agency contact title
Agency contact phone
Please enter a valid phone number.
Agency contact email
example@example.com
Please provide a detailed description of the suspected fraud
Supporting documentation and/or evidence exists and can be provided

YesNo
Please read and attest to each of the statements below by checking the corresponding box. All boxes must be checked before this report can be submitted*

I hereby affirm that the information provided in this report is true, complete and accurate to the best of my knowledge and belief.I understand that knowingly providing false information may be subject to penalties under the law and affirm my commitment to honesty and integrity in submitting this report.I acknowledge that the submission of this report does not relieve me of my obligations or responsibilities under applicable laws, policies or regulations. I understand that I remain responsible for conducting investigations, discovering evidence, withholding funding, or fulfilling any other duties as required by law, policy or established procedures.I acknowledge that this report does not serve as a substitute for any ongoing or future responsibilities and that I remain accountable for compliance with all applicable rules and requirements.
By pressing “SUBMIT” you have met your obligation to report known or suspected fraud to the Bureau of Criminal Apprehension Financial Crimes and Fraud Section, Minnesota Management and Budget, the Minnesota Department of Administration and the Minnesota Department of Revenue.

To report to the OLA please click HERE.
Please verify that you are human*
Should be Empty:

Report suspected state program fraud

Reporting party contact information and anonymous reporting party disclaimer

Suspect Information

Suspect information

Loss information

Suspect Financial/Banking Institution Information

Reporting