Derby Revs and Benefits

* Required Fields

This form is for Revenues and Benefits staff only.

Name of Referring Officer *

Job Title *

Council Tax Reference Number

Housing Benefit Reference Number

Type of Fraud *

Fraud Category *

Details of Customer

Forename *

Surname *

National Insurance Number

Date of Birth

First Language

Full Address

Address Line 1 *

Address Line 2 *

Address line 3

Postcode *

Other occupants listed in household

Please detail and list Names, Relationship to the customer and Date of Births here

Last contact made by Customer

Please confirm the last date the customer made contact

Housing Benefit and CTS amount

Housing Benefit

Council Tax Support

Details of the fraud

Date suspicion arose

Details

Source, where has the intel come from

Please provide Name, address and any contact information

Has the customer been written to or contacted regarding this allegation?

Yes

Further information

Any PV or Warnings

Please indicate if you are aware of any warning indicators or risks known to the person or the address that we need to be aware of *

If you stated YES! please provide details here

Uploading Files

Please upload any supporting documents and evidence below, if you are unable to please email the Counter Fraud Team on inspectionservice@derby.gov.uk.
Before submitting the form you can take a print of the form using the print feature using your web page provider, save a copy in the Enterprise file
Once accepted you should receive an email from the investigator confirming when it has been allocated, if this has not happened please contact Michael Sarjeant 01332 643143

File Upload

Send us any evidence you may have to support your referral.

Choose file to upload (Maximum file size allowed 50 MB)