Homeowner Assistance Fund Incident Report Form

Homeowner Assistance Fund Incident Report Form

This form should be used to report fraud or other incidents for further review. Please include as many details as possible.

Please choose an option:*

I would like to report anonymously.

I am OK with providing my information.

INCIDENT INFORMATION

Incident Type (s)*

Abuse of Program Benefits

Confidentiality/Privacy Issue

Conflict of Interest

Discrimination

Embezzlement

Falsification of Contracts or Records

Fraud

Harassment

Improper Giving or Receiving of Gifts

IT Security

Threat of Violence

Unusual or Suspicious Activities

Waste/Abuse

Other (If selected, please describe below.)

Property Address*

Unit / Space Number

City*

Zip Code*

What would you like to report? Please describe in as much detail as possible.*

When did the incident occur?

How did you become aware of the violation?

Were you targeted in any way?

No

Yes

Was there anyone else involved?

No

Yes

If yes, who was involved?

Has the incident been reported to anyone in the Homeowner Assistance Fund supervision or management team?

No

Yes

If yes, who did you report this to?

Has the incident been reported to anyone outside the organization?

No

Yes

If yes, who did you report this to?

REPORTER'S INFORMATION

Reported By*

Primary Phone Number*

Supporting Documents

File Attachments (If applicable)

Drag and drop files here or

Send me a copy of my responses

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