Program Violation Reporting Form | Housing Authority of the County of Santa Cruz

Housing Authority of the County of Santa Cruz
Program Integrity Office
2160 41st Avenue, Capitola, CA 95010
Phone: 831-454-9455, ext 251

Please give as much information and as many details as possible.
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PI
Name of 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:
MM slash DD slash YYYY
- 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?
- Lanlord 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:
First Last
Contact Phone Number:
Name:
First Last
Contact Phone Number:
OPTIONAL - Confidential Information
Giving your name and contact information is optional, however, we may need to ask you 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 website page for details)
Your Name:
Phone Number:
Email Address:*
Date:
MM slash DD slash YYYY