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COMPLAINT CALL / REPORT OF FRAUD
State Form 54013 (8-09) / FI 0113
Name ICES case number
Social Security number Date of birth (month, day, year)
Address (number and street, city, state, and ZIP code)
County number Date of call (month, day, year)
CALLER INFORMATION
Name Telephone number
( )
Keep caller name confidential from client. Anonymous call, no name given.
CASE STATUS
Active Pending Inactive
NATURE OF CALL
Give as many details as possible - where, what, when, who, and how.
Submitted by: Worker identification number