DDSSA -

DISABILITY DETERMINATION
FOR SOCIAL SECURITY ADMINISTRATION
Investigation Unit
COMPLAINT FORM QUESTIONNAIRE

The following information concerns the person or persons the complaint of potential fraud is about. Please complete the below information if known.

NAME:

(please include any aliases)

SSN

Date of Birth

(Enter Date of Birth or approximate age.)

ADDRESS:

TELEPHONE:

BRIEF DESCRIPTION OF PERSON:

NAMES OF FAMILY MEMBERS IN HOUSEHOLD:

TYPE & DESCRIPTION OF ALL VEHICLES BELONGING TO THE HOUSEHOLD:

LICENSE NUMBER OF ALL VEHICLES BELONGING TO THE HOUSEHOLD:

BASIS FOR COMPLAINT

Yes

No

IS THE PERSON THE COMPLAINT IS ABOUT WORKING?

How do you know he/she is working?

Who else knows he/she is working?

Type of business:

Name of business:

Business Address:

Business Phone:

Days of the week he/she works:

Su

M

Tu

W

Th

F

Sa

Hours of the day he/she works:

Approximate time he/she leaves for work:

Approximate time he/she returns from work:

Does the person the complaint is about do any of the following?
Yard Work:	Yes	No
If yes, please describe what type of yard work and how often



	Yes	No
Home Repairs:
If yes, please describe what type of home repairs and how often


	Yes	No
Sports:
If yes, please describe what type of sports and how often


	Yes	No
Other:
Comments:

	Yes	No
Would you like to leave your name and telephone number for future assistance or information?

If yes, please complete the information below.

SOURCE:

Relationship to Potential Subject:

Address & Telephone Number Of Source:


Other Sources:


Address & Telephone Number of Other Sources: