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Report Fraud | Office of Inspector General
<!DOCTYPE html> <html lang="en"> <head> <meta charset="UTF-8"> <meta name="viewport" content="width=device-width, initial-scale=1.0"> <!-- dynamically display page title --> <title>Report Fraud | Office of Inspector General</title> <!-- Google Tag Manager --> <script>(function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start': new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0], j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src= 'https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f); })(window,document,'script','dataLayer','GTM-5GQXH7Q');</script> <!-- End Google Tag Manager --> <link rel="shortcut icon" href="/oig/static/images/favicon.png"> <link rel="stylesheet" href="/oig/static/js/jquery-ui-1.13.2/jquery-ui.min.css"> <link rel="stylesheet" href="/oig/static/js/jquery-ui-1.13.2/jquery-ui.structure.min.css"> <link rel="stylesheet" href="/oig/static/js/jquery-ui-1.13.2/jquery-ui.theme.min.css"> <!-- bootstrap css --> <link rel="stylesheet" href="/oig/static/css/bootstrap/bootstrap.min.css"> <!-- fraud reports custom css --> <link rel="stylesheet" href="/oig/static/css/fraudreports/custom_fraud.css"> <!-- scam reports custom css --> <link rel="stylesheet" href="/oig/static/css/scamreports/custom_scam.css"> </head> <body> <!-- As a link --> <nav class="navbar bg-body-light"> <div class="container"> <a class="navbar-brand" href="https://www.ssa.gov/"> <img src="/oig/static/images/ssa-logo1.png" width='250' height='65'> </a> </div> </nav> <div class="container mb-3"> <!-- privacy act information --> <div id="privacyActInfo" class="col-md-12 mt-3"> <div class="alert alert-info alert-dismissible fade show" role="alert"> The Inspector General Act of 1978, as amended, allows the Office of the Inspector General (OIG) at the Social Security Administration (SSA) to collect your information, which OIG may use to investigate alleged fraud, waste, abuse, and misconduct related to SSA programs and operations. Providing the information is voluntary, but not providing all or part of the information may limit our ability to conduct a complete investigation. As law permits, we may use and share the information you submit, including with other Federal and local government agencies, and others, as outlined in the routine uses within System of Records Notices (SORN) OIG-001 and OIG-002, available at www.ssa.gov/privacy. When appropriate, the information you submit may also be provided to the SSA for use in computer matching programs to establish or verify eligibility for SSA programs and to recoup debts under these programs. All SSA SORNs are also available at www.ssa.gov/privacy. <button type="button" class="btn-close" data-bs-dismiss="alert" aria-label="Close"></button> </div> </div> <form method="post" id="form"> <input type="hidden" name="csrfmiddlewaretoken" value="N37w1Werf9g6CCQK8RvKFHvayFsVo9o0jEukz20ovZNPjuO0lGqbSvfv3S1Cx5P6"> <span class="asterisk">*</span> Indicates required information <div class="passwordField"> <label for="id_password" class="form-label">password</label> <input type="text" name="password" class="form-control" autocomplete="new-password" maxlength="100" id="id_password"> </div> <div id=""> <div class="bg-light p-4 mb-1 mt-2"> <h5 class="mb-2">Your Report Privacy <span class="asterisk">*</span></h5> <div class="col-md-12"> <label for="" class="form-label"> Please indicate the level of confidentiality and anonymity you would like this request to be handled with </label> <div class="col-md-12"> <div class="form-check mb-2"> <input type="radio" name="report_privacy" value="no_restrictions" class="form-check-input" maxlength="25" id="id_report_privacy_0" required checked> <label class="form-check-label" for="id_report_privacy_0">No Restrictions: You may contact me for additional information and I do not place any restrictions on the release of my contact information. </div> <div class="form-check mb-2"> <input type="radio" name="report_privacy" value="confidential" class="form-check-input" maxlength="25" id="id_report_privacy_1" required> <label class="form-check-label" for="id_report_privacy_1">Confidential: You may contact me for additional information. Do not share my name outside the Office of the Inspector General. </div> <div class="form-check mb-2"> <input type="radio" name="report_privacy" value="anonymous" class="form-check-input" maxlength="25" id="id_report_privacy_2" required> <label class="form-check-label" for="id_report_privacy_2">Anonymous: I do not wish to provide any contact information. </div> </div> </div> </div> <!-- about you section --> <div id="aboutComplainant"> <div class="bg-light p-4 mb-1 mt-3"> <h5 class="mb-2">About You</h5> <div class="col-md-12"> <label for="inputReporter" class="form-label">Are you filing a report as a private individual or on behalf of a business?</label> <div class="col-md-4"> <select name="individual_or_biz" class="form-select" id="inputReporter" maxlength="25"> <option value="Individual">Individual</option> <option value="Business">Business</option> </select> </div> </div> </div> <div id="complainantContactFields" class="bg-light p-4 pb-0 mb-1 mt-3"> <h5 id="contactInfoTitle" class="mb-2">Your Contact Information</h5> <div id="indiContactInfo"> <div class="row"> <div class="col-md-4 mb-1"> <label for="compIndiVicStatus" class="form-label m-0">Victim Status</label> <div id="compIndiVicStatusHelp" class="form-text">are you the victim of the violation/fraud?</div> <select name="victim_status" class="form-select" id="compIndiVicStatus" maxlength="4"> <option value="" selected></option> <option value="Yes">Yes, I'm the victim</option> <option value="No">No, I'm not the victim</option> </select> </div> <div class="col-md-4 mb-1"> <label for="compIndiEmail" class="form-label m-0">Email</label> <div id="compIndiEmailHelp" class="form-text">please enter your email</div> <input type="email" name="email" class="form-control" id="compIndiEmail" maxlength="45"> </div> <div class="col-md-4 mb-1"> <label for="compIndiSsn" class="form-label m-0">Social Security Number (SSN)</label> <div id="compIndiSsnHelp" class="form-text">your SSN will be kept confidential</div> <input type="password" name="ssn" class="form-control" id="compIndiSsn" maxlength="11"> </div> </div> <!-- individual name --> <div class="row mt-2"> <div class="col-md-4 mb-1"> <label for="compIndiFirst" class="form-label">First name</label> <input type="text" name="first_name" class="form-control" id="compIndiFirst" maxlength="20"> </div> <div class="col-md-3 mb-1"> <label for="compIndiMiddle" class="form-label">Middle name</label> <input type="text" name="middle_name" class="form-control" id="compIndiMiddle" maxlength="20"> </div> <div class="col-md-4 mb-1"> <label for="compIndiLast" class="form-label">Last name</label> <input type="text" name="last_name" class="form-control" id="compIndiLast" maxlength="40"> </div> <div class="col-md-1 mb-1"> <label for="compIndiSuffix" class="form-label">Suffix</label> <select name="suffix" class="form-select" id="compIndiSuffix" maxlength="20"> <option value="" selected></option> <option value="Jr">Jr</option> <option value="Sr">Sr</option> <option value="I">I</option> <option value="II">II</option> <option value="III">III</option> <option value="IV">IV</option> <option value="V">V</option> </select> </div> </div> <!-- individual address --> <div class="row"> <div class="col-md-6 mb-1"> <label for="compIndiStreetAddress" class="form-label">Street address</label> <input type="text" name="street" class="form-control" id="compIndiStreetAddress" maxlength="100"> </div> <div class="col-md-6 mb-1"> <label for="compIndiBuilding" class="form-label">Apartment, suite, building, etc...</label> <input type="text" name="building" class="form-control" id="compIndiBuilding" maxlength="100"> </div> </div> <div class="row mt-2"> <div class="col-md-4 mb-1"> <label for="compIndiCity" class="form-label">City/town</label> <input type="text" name="city" class="form-control" id="compIndiCity" maxlength="35"> </div> <div class="col-md-2 mb-1"> <label for="compIndiState" class="form-label">State</label> <select name="state" class="form-select" id="compIndiState" maxlength="2"> <option value="" selected></option> <option value="AL">Alabama</option> <option value="AK">Alaska</option> <option value="AS">American Samoa</option> <option value="AZ">Arizona</option> <option value="AR">Arkansas</option> <option value="CA">California</option> <option value="CO">Colorado</option> <option value="CT">Connecticut</option> <option value="DE">Delaware</option> <option value="FL">Florida</option> <option value="GA">Georgia</option> <option value="GU">Guam</option> <option value="HI">Hawaii</option> <option value="ID">Idaho</option> <option value="IL">Illinois</option> <option value="IN">Indiana</option> <option value="IA">Iowa</option> <option value="KS">Kansas</option> <option value="KY">Kentucky</option> <option value="LA">Louisiana</option> <option value="ME">Maine</option> <option value="MD">Maryland</option> <option value="MA">Massachusetts</option> <option value="MI">Michigan</option> <option value="MN">Minnesota</option> <option value="MS">Mississippi</option> <option value="MO">Missouri</option> <option value="MT">Montana</option> <option value="NE">Nebraska</option> <option value="NV">Nevada</option> <option value="NH">New Hampshire</option> <option value="NJ">New Jersey</option> <option value="NM">New Mexico</option> <option value="NY">New York</option> <option value="NC">North Carolina</option> <option value="ND">North Dakota</option> <option value="MP">Northern Mariana Islands</option> <option value="OH">Ohio</option> <option value="OK">Oklahoma</option> <option value="OR">Oregon</option> <option value="PA">Pennsylvania</option> <option value="PR">Puerto Rico</option> <option value="RI">Rhode Island</option> <option value="SC">South Carolina</option> <option value="SD">South Dakota</option> <option value="TN">Tennessee</option> <option value="TX">Texas</option> <option value="VI">U.S. Virgin Islands</option> <option value="UT">Utah</option> <option value="VT">Vermont</option> <option value="VA">Virginia</option> <option value="WA">Washington</option> <option value="WV">West Virginia</option> <option value="WI">Wisconsin</option> <option value="WY">Wyoming</option> </select> </div> <div class="col-md-2 mb-1"> <label for="compIndiZipcode" class="form-label">Zip code</label> <input type="text" name="zip_code" class="form-control" id="compIndiZipcode" maxlength="10"> </div> </div> <!-- individual phones --> <div class="row mt-2"> <div class="col-md-3 col-sm-12 mb-3"> <label for="compIndiHomePhone" class="form-label">Home phone</label> <input type="text" name="home_phone" class="form-control" id="compIndiHomePhone" maxlength="14"> </div> <div class="col-md-3 col-sm-12 mb-3"> <label for="compIndiCellPhone" class="form-label">Cell phone</label> <input type="text" name="cell_phone" class="form-control" id="compIndiCellPhone" maxlength="14"> </div> <div class="col-md-3 col-sm-12 mb-3"> <label for="compIndiWorkPhone" class="form-label">Work phone</label> <input type="text" name="work_phone" class="form-control" id="compIndiWorkPhone" maxlength="14"> </div> <div class="col-md-2 col-sm-12 mb-3"> <label for="compIndiWorkPhoneExt" class="form-label">Work phone extension</label> <input type="text" name="work_phone_extension" class="form-control" id="compIndiWorkPhoneExt" maxlength="5"> </div> </div> </div> <div id="bizContactInfo"> <!-- business info row 1--> <div class="row"> <div class="col-md-6 mb-1"> <label for="compBizName" class="form-label">Business name</label> <input type="text" name="business_name" class="form-control" id="compBizName" maxlength="35"> </div> <div class="col-md-6 mb-1"> <label for="compBizEin" class="form-label">Employer Identification Number (EIN)</label> <input type="text" name="business_ein" class="form-control" id="compBizEin" maxlength="9"> </div> </div> <!-- business address --> <div class="row"> <div class="col-md-6 mb-1"> <label for="compBizStreetAddress" class="form-label">Street address</label> <input type="text" name="business_street" class="form-control" id="compBizStreetAddress" maxlength="100"> </div> <div class="col-md-6 mb-1"> <label for="compBizBuilding" class="form-label">Apartment, suite, building, etc...</label> <input type="text" name="business_building" class="form-control" id="compBizBuilding" maxlength="100"> </div> </div> <div class="row mt-2"> <div class="col-md-4 mb-1"> <label for="compBizCity" class="form-label">City/town</label> <input type="text" name="business_city" class="form-control" id="compBizCity" maxlength="35"> </div> <div class="col-md-2 mb-1"> <label for="compBizState" class="form-label">State</label> <select name="business_state" class="form-select" id="compBizState" maxlength="2"> <option value="" selected></option> <option value="AL">Alabama</option> <option value="AK">Alaska</option> <option value="AS">American Samoa</option> <option value="AZ">Arizona</option> <option value="AR">Arkansas</option> <option value="CA">California</option> <option value="CO">Colorado</option> <option value="CT">Connecticut</option> <option value="DE">Delaware</option> <option value="FL">Florida</option> <option value="GA">Georgia</option> <option value="GU">Guam</option> <option value="HI">Hawaii</option> <option value="ID">Idaho</option> <option value="IL">Illinois</option> <option value="IN">Indiana</option> <option value="IA">Iowa</option> <option value="KS">Kansas</option> <option value="KY">Kentucky</option> <option value="LA">Louisiana</option> <option value="ME">Maine</option> <option value="MD">Maryland</option> <option value="MA">Massachusetts</option> <option value="MI">Michigan</option> <option value="MN">Minnesota</option> <option value="MS">Mississippi</option> <option value="MO">Missouri</option> <option value="MT">Montana</option> <option value="NE">Nebraska</option> <option value="NV">Nevada</option> <option value="NH">New Hampshire</option> <option value="NJ">New Jersey</option> <option value="NM">New Mexico</option> <option value="NY">New York</option> <option value="NC">North Carolina</option> <option value="ND">North Dakota</option> <option value="MP">Northern Mariana Islands</option> <option value="OH">Ohio</option> <option value="OK">Oklahoma</option> <option value="OR">Oregon</option> <option value="PA">Pennsylvania</option> <option value="PR">Puerto Rico</option> <option value="RI">Rhode Island</option> <option value="SC">South Carolina</option> <option value="SD">South Dakota</option> <option value="TN">Tennessee</option> <option value="TX">Texas</option> <option value="VI">U.S. Virgin Islands</option> <option value="UT">Utah</option> <option value="VT">Vermont</option> <option value="VA">Virginia</option> <option value="WA">Washington</option> <option value="WV">West Virginia</option> <option value="WI">Wisconsin</option> <option value="WY">Wyoming</option> </select> </div> <div class="col-md-2 mb-1"> <label for="compBizZipcode" class="form-label">Zip code</label> <input type="text" name="business_zip_code" class="form-control" id="compBizZipcode" maxlength="10"> </div> </div> <!-- business phones --> <div class="row mt-2 pb-3"> <div class="col-md-3 mb-1"> <label for="compBizPhone" class="form-label">Business phone</label> <input type="text" name="business_phone" class="form-control" id="compBizPhone" maxlength="14"> </div> <div class="col-md-3 mb-1"> <label for="compBizCellPhone" class="form-label">Business cell phone</label> <input type="text" name="business_cell_phone" class="form-control" id="compBizCellPhone" maxlength="14"> </div> </div> </div> </div> </div> <input type="hidden" name="subject_set-TOTAL_FORMS" value="1" id="id_subject_set-TOTAL_FORMS"><input type="hidden" name="subject_set-INITIAL_FORMS" value="0" id="id_subject_set-INITIAL_FORMS"><input type="hidden" name="subject_set-MIN_NUM_FORMS" value="0" id="id_subject_set-MIN_NUM_FORMS"><input type="hidden" name="subject_set-MAX_NUM_FORMS" value="1000" id="id_subject_set-MAX_NUM_FORMS"> <div id="subject-list"> <div class="subject-formset-container subject_set"> <div id="subject-form"> <!-- subject formset --> <div id="subject_set-__prefix__-formfields"> <div class="bg-light p-4 mt-3 mb-1 pb-0"> <h5 class="mb-2">The Individual or Business Committing Fraud, Waste, Abuse</h5> <label class="form-label">Please describe the individual or business committing fraud, waste, abuse</label> <!-- select individual/business engaged in fraud --> <div class="bg-light mt-4"> <div class="row mt-2"> <label for="inputFraudster-__prefix__" class="form-label">Did an individual or business commit fraud, waste, abuse?</label> <div id="inputFraudster-__prefix__" class="col-sm-12 col-md-4"> <select name="subject_set-0-individual_or_biz" class="form-select" maxlength="25" id="id_subject_set-0-individual_or_biz"> <option value="Individual">Individual</option> <option value="Business">Business</option> </select> </div> </div> </div> <div id="subject_set-indiFraud-0" class="indiFraud mt-2"> <!-- individual contact info --> <div class="row"> <div class="col-md-4 mb-3"> <label for="id_subject_set-__prefix__-first_name" class="form-label">First name</label> <input type="text" name="subject_set-0-first_name" class="form-control" maxlength="20" id="id_subject_set-0-first_name"> </div> <div class="col-md-3 mb-3"> <label for="id_subject_set-__prefix__-middle_name" class="form-label">Middle name</label> <input type="text" name="subject_set-0-middle_name" class="form-control" maxlength="20" id="id_subject_set-0-middle_name"> </div> <div class="col-md-4 mb-3"> <label for="id_subject_set-__prefix__-last_name" class="form-label">Last name</label> <input type="text" name="subject_set-0-last_name" class="form-control" maxlength="40" id="id_subject_set-0-last_name"> </div> <div class="col-md-1 mb-3"> <label for="id_subject_set-__prefix__-suffix" class="form-label">Suffix</label> <select name="subject_set-0-suffix" class="form-select" maxlength="25" id="id_subject_set-0-suffix"> <option value="" selected></option> <option value="Jr">Jr</option> <option value="Sr">Sr</option> <option value="I">I</option> <option value="II">II</option> <option value="III">III</option> <option value="IV">IV</option> <option value="V">V</option> </select> </div> </div> <div class="row"> <div class="col-md-6 mb-3"> <label for="id_subject_set-__prefix__-alias" class="form-label">Alias</label> <div id="emailHelp" class="form-text">other names this individual may have been known by</div> <input type="text" name="subject_set-0-alias" class="form-control" maxlength="35" id="id_subject_set-0-alias"> </div> <div class="col-md-6 mb-3"> <label for="id_subject_set-__prefix__-ssn" class="form-label">Social Security Number (SSN)</label> <div id="ssnHelp" class="form-text">The SSN of the person committing fraud, waste, abuse if known</div> <input type="password" name="subject_set-0-ssn" class="form-control" maxlength="11" id="id_subject_set-0-ssn"> </div> </div> <!-- individual address row 1 --> <div class="row"> <div class="col-md-6 mb-3"> <label for="id_subject_set-__prefix__-street" class="form-label">Street Address</label> <input type="text" name="subject_set-0-street" class="form-control" maxlength="100" id="id_subject_set-0-street"> </div> <div class="col-md-6 mb-3"> <label for="id_subject_set-__prefix__-building" class="form-label">Apartment, suite, building, etc...</label> <input type="text" name="subject_set-0-building" class="form-control" maxlength="100" id="id_subject_set-0-building"> </div> </div> <!-- individual address row 2 --> <div class="row mt-2"> <div class="col-md-4 mb-3"> <label for="id_subject_set-__prefix__-city" class="form-label">City/town</label> <input type="text" name="subject_set-0-city" class="form-control" maxlength="25" id="id_subject_set-0-city"> </div> <div class="col-md-2 mb-3"> <label for="id_subject_set-__prefix__-state" class="form-label">State</label> <select name="subject_set-0-state" class="form-select" maxlength="2" id="id_subject_set-0-state"> <option value="" selected></option> <option value="AL">Alabama</option> <option value="AK">Alaska</option> <option value="AS">American Samoa</option> <option value="AZ">Arizona</option> <option value="AR">Arkansas</option> <option value="CA">California</option> <option value="CO">Colorado</option> <option value="CT">Connecticut</option> <option value="DE">Delaware</option> <option value="FL">Florida</option> <option value="GA">Georgia</option> <option value="GU">Guam</option> <option value="HI">Hawaii</option> <option value="ID">Idaho</option> <option value="IL">Illinois</option> <option value="IN">Indiana</option> <option value="IA">Iowa</option> <option value="KS">Kansas</option> <option value="KY">Kentucky</option> <option value="LA">Louisiana</option> <option value="ME">Maine</option> <option value="MD">Maryland</option> <option value="MA">Massachusetts</option> <option value="MI">Michigan</option> <option value="MN">Minnesota</option> <option value="MS">Mississippi</option> <option value="MO">Missouri</option> <option value="MT">Montana</option> <option value="NE">Nebraska</option> <option value="NV">Nevada</option> <option value="NH">New Hampshire</option> <option value="NJ">New Jersey</option> <option value="NM">New Mexico</option> <option value="NY">New York</option> <option value="NC">North Carolina</option> <option value="ND">North Dakota</option> <option value="MP">Northern Mariana Islands</option> <option value="OH">Ohio</option> <option value="OK">Oklahoma</option> <option value="OR">Oregon</option> <option value="PA">Pennsylvania</option> <option value="PR">Puerto Rico</option> <option value="RI">Rhode Island</option> <option value="SC">South Carolina</option> <option value="SD">South Dakota</option> <option value="TN">Tennessee</option> <option value="TX">Texas</option> <option value="VI">U.S. Virgin Islands</option> <option value="UT">Utah</option> <option value="VT">Vermont</option> <option value="VA">Virginia</option> <option value="WA">Washington</option> <option value="WV">West Virginia</option> <option value="WI">Wisconsin</option> <option value="WY">Wyoming</option> </select> </div> <div class="col-md-2 mb-3"> <label for="id_subject_set-__prefix__-zip_code" class="form-label">Zip code</label> <input type="text" name="subject_set-0-zip_code" class="form-control" maxlength="10" id="id_subject_set-0-zip_code"> </div> </div> <!-- individual phones --> <div class="row mt-2"> <div class="col-md-3 col-sm-12 mb-3"> <label for="id_subject_set-__prefix__-home_phone" class="form-label">Home phone</label> <input type="text" name="subject_set-0-home_phone" class="form-control" maxlength="14" id="id_subject_set-0-home_phone"> </div> <div class="col-md-3 col-sm-12 mb-3"> <label for="id_subject_set-__prefix__-cell_phone" class="form-label">Cell phone</label> <input type="text" name="subject_set-0-cell_phone" class="form-control" maxlength="14" id="id_subject_set-0-cell_phone"> </div> <div class="col-md-3 col-sm-12 mb-3"> <label for="id_subject_set-__prefix__-work_phone" class="form-label">Work phone</label> <input type="text" name="subject_set-0-work_phone" class="form-control" maxlength="14" id="id_subject_set-0-work_phone"> </div> <div class="col-md-2 col-sm-12 mb-3"> <label for="id_subject_set-__prefix__-work_phone_extension" class="form-label">Work phone extension</label> <input type="text" name="subject_set-0-work_phone_extension" class="form-control" maxlength="5" id="id_subject_set-0-work_phone_extension"> </div> </div> </div> <div id="subject_set-bizFraud-0" class="bizFraud hidden mt-2"> <!-- business info --> <div class="row"> <div class="col-md-6 mb-3"> <label for="id_subject_set-0-business_name" class="form-label">Business Name</label> <input type="text" name="subject_set-0-business_name" class="form-control" maxlength="35" id="id_subject_set-0-business_name"> </div> <div class="col-md-6 mb-3"> <label for="id_subject_set-0-business_ein" class="form-label">Business EIN</label> <input type="text" name="subject_set-0-business_ein" class="form-control" maxlength="9" id="id_subject_set-0-business_ein"> </div> </div> <!-- business address --> <div class="row"> <div class="col-md-6 mb-1"> <label for="id_subject_set-0-business_street_address" class="form-label">Street address</label> <input type="text" name="subject_set-0-business_street" class="form-control" maxlength="100" id="id_subject_set-0-business_street"> </div> <div class="col-md-6 mb-1"> <label for="id_subject_set-0-business_building" class="form-label">Apartment, suite, building, etc...</label> <input type="text" name="subject_set-0-business_building" class="form-control" maxlength="100" id="id_subject_set-0-business_building"> </div> </div> <div class="row mt-2"> <div class="col-md-4 mb-1"> <label for="id_subject_set-0-business_city" class="form-label">City/town</label> <input type="text" name="subject_set-0-business_city" class="form-control" maxlength="35" id="id_subject_set-0-business_city"> </div> <div class="col-md-2 mb-1"> <label for="id_subject_set-0-business_state" class="form-label">State</label> <select name="subject_set-0-business_state" class="form-select" maxlength="2" id="id_subject_set-0-business_state"> <option value="" selected></option> <option value="AL">Alabama</option> <option value="AK">Alaska</option> <option value="AS">American Samoa</option> <option value="AZ">Arizona</option> <option value="AR">Arkansas</option> <option value="CA">California</option> <option value="CO">Colorado</option> <option value="CT">Connecticut</option> <option value="DE">Delaware</option> <option value="FL">Florida</option> <option value="GA">Georgia</option> <option value="GU">Guam</option> <option value="HI">Hawaii</option> <option value="ID">Idaho</option> <option value="IL">Illinois</option> <option value="IN">Indiana</option> <option value="IA">Iowa</option> <option value="KS">Kansas</option> <option value="KY">Kentucky</option> <option value="LA">Louisiana</option> <option value="ME">Maine</option> <option value="MD">Maryland</option> <option value="MA">Massachusetts</option> <option value="MI">Michigan</option> <option value="MN">Minnesota</option> <option value="MS">Mississippi</option> <option value="MO">Missouri</option> <option value="MT">Montana</option> <option value="NE">Nebraska</option> <option value="NV">Nevada</option> <option value="NH">New Hampshire</option> <option value="NJ">New Jersey</option> <option value="NM">New Mexico</option> <option value="NY">New York</option> <option value="NC">North Carolina</option> <option value="ND">North Dakota</option> <option value="MP">Northern Mariana Islands</option> <option value="OH">Ohio</option> <option value="OK">Oklahoma</option> <option value="OR">Oregon</option> <option value="PA">Pennsylvania</option> <option value="PR">Puerto Rico</option> <option value="RI">Rhode Island</option> <option value="SC">South Carolina</option> <option value="SD">South Dakota</option> <option value="TN">Tennessee</option> <option value="TX">Texas</option> <option value="VI">U.S. Virgin Islands</option> <option value="UT">Utah</option> <option value="VT">Vermont</option> <option value="VA">Virginia</option> <option value="WA">Washington</option> <option value="WV">West Virginia</option> <option value="WI">Wisconsin</option> <option value="WY">Wyoming</option> </select> </div> <div class="col-md-2 mb-1"> <label for="id_subject_set-0-business_zip_code" class="form-label">Zip code</label> <input type="text" name="subject_set-0-business_zip_code" class="form-control" maxlength="10" id="id_subject_set-0-business_zip_code"> </div> </div> <!-- business phones --> <div class="row mt-2 pb-3"> <div class="col-md-3 mb-1"> <label for="id_subject_set-0-business_phone" class="form-label">Business phone</label> <input type="text" name="subject_set-0-business_phone" class="form-control" maxlength="14" id="id_subject_set-0-business_phone"> </div> <div class="col-md-3 mb-1"> <label for="id_subject_set-0-business_cell_phone" class="form-label">Business cell phone</label> <input type="text" name="subject_set-0-business_cell_phone" class="form-control" maxlength="14" id="id_subject_set-0-business_cell_phone"> </div> </div> </div> <div id="subject_set-demographics-__prefix__" class="demoFraud"> <h5 class="mb-2 mt-2">Subject Demographics</h5> <label class="form-label">Please provide demographic information regarding the subject</label> <!-- subject demographics --> <div class="row"> <div class="col-md-3 mb-3"> <label for="id_subject_set-__prefix__-race" class="form-label">Race</label> <select name="subject_set-0-race" class="form-select" maxlength="20" id="id_subject_set-0-race"> <option value="" selected></option> <option value="asian">Asian</option> <option value="black">Black</option> <option value="hispanic">Hispanic</option> <option value="indian">NA Indian\Alaskan</option> <option value="other">Other</option> <option value="unknown">Unknown</option> <option value="white">White</option> </select> </div> <div class="col-md-3 mb-3"> <label for="id_subject_set-__prefix__-gender" class="form-label">Sex</label> <select name="subject_set-0-gender" class="form-select" maxlength="1" id="id_subject_set-0-gender"> <option value="" selected></option> <option value="M">Male</option> <option value="F">Female</option> </select> </div> <div class="col-md-3 mb-3"> <label for="inputSubjectDemoBirthDay" class="form-label">Birthday</label> <div class="input-group"> <input type="date" name="subject_set-0-birthday" class="form-control" id="id_subject_set-0-birthday"> </div> </div> <div class="col-md-2 mb-3"> <label for="id_subject_set-__prefix__-birth_state" class="form-label">State of Birth</label> <select name="subject_set-0-birth_state" class="form-select" maxlength="2" id="id_subject_set-0-birth_state"> <option value="" selected></option> <option value="AL">Alabama</option> <option value="AK">Alaska</option> <option value="AS">American Samoa</option> <option value="AZ">Arizona</option> <option value="AR">Arkansas</option> <option value="CA">California</option> <option value="CO">Colorado</option> <option value="CT">Connecticut</option> <option value="DE">Delaware</option> <option value="FL">Florida</option> <option value="GA">Georgia</option> <option value="GU">Guam</option> <option value="HI">Hawaii</option> <option value="ID">Idaho</option> <option value="IL">Illinois</option> <option value="IN">Indiana</option> <option value="IA">Iowa</option> <option value="KS">Kansas</option> <option value="KY">Kentucky</option> <option value="LA">Louisiana</option> <option value="ME">Maine</option> <option value="MD">Maryland</option> <option value="MA">Massachusetts</option> <option value="MI">Michigan</option> <option value="MN">Minnesota</option> <option value="MS">Mississippi</option> <option value="MO">Missouri</option> <option value="MT">Montana</option> <option value="NE">Nebraska</option> <option value="NV">Nevada</option> <option value="NH">New Hampshire</option> <option value="NJ">New Jersey</option> <option value="NM">New Mexico</option> <option value="NY">New York</option> <option value="NC">North Carolina</option> <option value="ND">North Dakota</option> <option value="MP">Northern Mariana Islands</option> <option value="OH">Ohio</option> <option value="OK">Oklahoma</option> <option value="OR">Oregon</option> <option value="PA">Pennsylvania</option> <option value="PR">Puerto Rico</option> <option value="RI">Rhode Island</option> <option value="SC">South Carolina</option> <option value="SD">South Dakota</option> <option value="TN">Tennessee</option> <option value="TX">Texas</option> <option value="VI">U.S. Virgin Islands</option> <option value="UT">Utah</option> <option value="VT">Vermont</option> <option value="VA">Virginia</option> <option value="WA">Washington</option> <option value="WV">West Virginia</option> <option value="WI">Wisconsin</option> <option value="WY">Wyoming</option> </select> </div> </div> </div> </div> </div> </div> </div> </div> <!-- empty form to clone --> <div id="empty-subject-form" class="hidden"> <!-- subject formset --> <div id="subject_set-__prefix__-formfields"> <div class="bg-light p-4 mt-3 mb-1 pb-0"> <h5 class="mb-2">The Individual or Business Committing Fraud, Waste, Abuse</h5> <label class="form-label">Please describe the individual or business committing fraud, waste, abuse</label> <!-- select individual/business engaged in fraud --> <div class="bg-light mt-4"> <div class="row mt-2"> <label for="inputFraudster-__prefix__" class="form-label">Did an individual or business commit fraud, waste, abuse?</label> <div id="inputFraudster-__prefix__" class="col-sm-12 col-md-4"> <select name="subject_set-__prefix__-individual_or_biz" class="form-select" maxlength="25" id="id_subject_set-__prefix__-individual_or_biz"> <option value="Individual">Individual</option> <option value="Business">Business</option> </select> </div> </div> </div> <div id="subject_set-indiFraud-0" class="indiFraud mt-2"> <!-- individual contact info --> <div class="row"> <div class="col-md-4 mb-3"> <label for="id_subject_set-__prefix__-first_name" class="form-label">First name</label> <input type="text" name="subject_set-__prefix__-first_name" class="form-control" maxlength="20" id="id_subject_set-__prefix__-first_name"> </div> <div class="col-md-3 mb-3"> <label for="id_subject_set-__prefix__-middle_name" class="form-label">Middle name</label> <input type="text" name="subject_set-__prefix__-middle_name" class="form-control" maxlength="20" id="id_subject_set-__prefix__-middle_name"> </div> <div class="col-md-4 mb-3"> <label for="id_subject_set-__prefix__-last_name" class="form-label">Last name</label> <input type="text" name="subject_set-__prefix__-last_name" class="form-control" maxlength="40" id="id_subject_set-__prefix__-last_name"> </div> <div class="col-md-1 mb-3"> <label for="id_subject_set-__prefix__-suffix" class="form-label">Suffix</label> <select name="subject_set-__prefix__-suffix" class="form-select" maxlength="25" id="id_subject_set-__prefix__-suffix"> <option value="" selected></option> <option value="Jr">Jr</option> <option value="Sr">Sr</option> <option value="I">I</option> <option value="II">II</option> <option value="III">III</option> <option value="IV">IV</option> <option value="V">V</option> </select> </div> </div> <div class="row"> <div class="col-md-6 mb-3"> <label for="id_subject_set-__prefix__-alias" class="form-label">Alias</label> <div id="emailHelp" class="form-text">other names this individual may have been known by</div> <input type="text" name="subject_set-__prefix__-alias" class="form-control" maxlength="35" id="id_subject_set-__prefix__-alias"> </div> <div class="col-md-6 mb-3"> <label for="id_subject_set-__prefix__-ssn" class="form-label">Social Security Number (SSN)</label> <div id="ssnHelp" class="form-text">The SSN of the person committing fraud, waste, abuse if known</div> <input type="password" name="subject_set-__prefix__-ssn" class="form-control" maxlength="11" id="id_subject_set-__prefix__-ssn"> </div> </div> <!-- individual address row 1 --> <div class="row"> <div class="col-md-6 mb-3"> <label for="id_subject_set-__prefix__-street" class="form-label">Street Address</label> <input type="text" name="subject_set-__prefix__-street" class="form-control" maxlength="100" id="id_subject_set-__prefix__-street"> </div> <div class="col-md-6 mb-3"> <label for="id_subject_set-__prefix__-building" class="form-label">Apartment, suite, building, etc...</label> <input type="text" name="subject_set-__prefix__-building" class="form-control" maxlength="100" id="id_subject_set-__prefix__-building"> </div> </div> <!-- individual address row 2 --> <div class="row mt-2"> <div class="col-md-4 mb-3"> <label for="id_subject_set-__prefix__-city" class="form-label">City/town</label> <input type="text" name="subject_set-__prefix__-city" class="form-control" maxlength="25" id="id_subject_set-__prefix__-city"> </div> <div class="col-md-2 mb-3"> <label for="id_subject_set-__prefix__-state" class="form-label">State</label> <select name="subject_set-__prefix__-state" class="form-select" maxlength="2" id="id_subject_set-__prefix__-state"> <option value="" selected></option> <option value="AL">Alabama</option> <option value="AK">Alaska</option> <option value="AS">American Samoa</option> <option value="AZ">Arizona</option> <option value="AR">Arkansas</option> <option value="CA">California</option> <option value="CO">Colorado</option> <option value="CT">Connecticut</option> <option value="DE">Delaware</option> <option value="FL">Florida</option> <option value="GA">Georgia</option> <option value="GU">Guam</option> <option value="HI">Hawaii</option> <option value="ID">Idaho</option> <option value="IL">Illinois</option> <option value="IN">Indiana</option> <option value="IA">Iowa</option> <option value="KS">Kansas</option> <option value="KY">Kentucky</option> <option value="LA">Louisiana</option> <option value="ME">Maine</option> <option value="MD">Maryland</option> <option value="MA">Massachusetts</option> <option value="MI">Michigan</option> <option value="MN">Minnesota</option> <option value="MS">Mississippi</option> <option value="MO">Missouri</option> <option value="MT">Montana</option> <option value="NE">Nebraska</option> <option value="NV">Nevada</option> <option value="NH">New Hampshire</option> <option value="NJ">New Jersey</option> <option value="NM">New Mexico</option> <option value="NY">New York</option> <option value="NC">North Carolina</option> <option value="ND">North Dakota</option> <option value="MP">Northern Mariana Islands</option> <option value="OH">Ohio</option> <option value="OK">Oklahoma</option> <option value="OR">Oregon</option> <option value="PA">Pennsylvania</option> <option value="PR">Puerto Rico</option> <option value="RI">Rhode Island</option> <option value="SC">South Carolina</option> <option value="SD">South Dakota</option> <option value="TN">Tennessee</option> <option value="TX">Texas</option> <option value="VI">U.S. Virgin Islands</option> <option value="UT">Utah</option> <option value="VT">Vermont</option> <option value="VA">Virginia</option> <option value="WA">Washington</option> <option value="WV">West Virginia</option> <option value="WI">Wisconsin</option> <option value="WY">Wyoming</option> </select> </div> <div class="col-md-2 mb-3"> <label for="id_subject_set-__prefix__-zip_code" class="form-label">Zip code</label> <input type="text" name="subject_set-__prefix__-zip_code" class="form-control" maxlength="10" id="id_subject_set-__prefix__-zip_code"> </div> </div> <!-- individual phones --> <div class="row mt-2"> <div class="col-md-3 col-sm-12 mb-3"> <label for="id_subject_set-__prefix__-home_phone" class="form-label">Home phone</label> <input type="text" name="subject_set-__prefix__-home_phone" class="form-control" maxlength="14" id="id_subject_set-__prefix__-home_phone"> </div> <div class="col-md-3 col-sm-12 mb-3"> <label for="id_subject_set-__prefix__-cell_phone" class="form-label">Cell phone</label> <input type="text" name="subject_set-__prefix__-cell_phone" class="form-control" maxlength="14" id="id_subject_set-__prefix__-cell_phone"> </div> <div class="col-md-3 col-sm-12 mb-3"> <label for="id_subject_set-__prefix__-work_phone" class="form-label">Work phone</label> <input type="text" name="subject_set-__prefix__-work_phone" class="form-control" maxlength="14" id="id_subject_set-__prefix__-work_phone"> </div> <div class="col-md-2 col-sm-12 mb-3"> <label for="id_subject_set-__prefix__-work_phone_extension" class="form-label">Work phone extension</label> <input type="text" name="subject_set-__prefix__-work_phone_extension" class="form-control" maxlength="5" id="id_subject_set-__prefix__-work_phone_extension"> </div> </div> </div> <div id="subject_set-bizFraud-0" class="bizFraud hidden mt-2"> <!-- business info --> <div class="row"> <div class="col-md-6 mb-3"> <label for="id_subject_set-0-business_name" class="form-label">Business Name</label> <input type="text" name="subject_set-__prefix__-business_name" class="form-control" maxlength="35" id="id_subject_set-__prefix__-business_name"> </div> <div class="col-md-6 mb-3"> <label for="id_subject_set-0-business_ein" class="form-label">Business EIN</label> <input type="text" name="subject_set-__prefix__-business_ein" class="form-control" maxlength="9" id="id_subject_set-__prefix__-business_ein"> </div> </div> <!-- business address --> <div class="row"> <div class="col-md-6 mb-1"> <label for="id_subject_set-0-business_street_address" class="form-label">Street address</label> <input type="text" name="subject_set-__prefix__-business_street" class="form-control" maxlength="100" id="id_subject_set-__prefix__-business_street"> </div> <div class="col-md-6 mb-1"> <label for="id_subject_set-0-business_building" class="form-label">Apartment, suite, building, etc...</label> <input type="text" name="subject_set-__prefix__-business_building" class="form-control" maxlength="100" id="id_subject_set-__prefix__-business_building"> </div> </div> <div class="row mt-2"> <div class="col-md-4 mb-1"> <label for="id_subject_set-0-business_city" class="form-label">City/town</label> <input type="text" name="subject_set-__prefix__-business_city" class="form-control" maxlength="35" id="id_subject_set-__prefix__-business_city"> </div> <div class="col-md-2 mb-1"> <label for="id_subject_set-0-business_state" class="form-label">State</label> <select name="subject_set-__prefix__-business_state" class="form-select" maxlength="2" id="id_subject_set-__prefix__-business_state"> <option value="" selected></option> <option value="AL">Alabama</option> <option value="AK">Alaska</option> <option value="AS">American Samoa</option> <option value="AZ">Arizona</option> <option value="AR">Arkansas</option> <option value="CA">California</option> <option value="CO">Colorado</option> <option value="CT">Connecticut</option> <option value="DE">Delaware</option> <option value="FL">Florida</option> <option value="GA">Georgia</option> <option value="GU">Guam</option> <option value="HI">Hawaii</option> <option value="ID">Idaho</option> <option value="IL">Illinois</option> <option value="IN">Indiana</option> <option value="IA">Iowa</option> <option value="KS">Kansas</option> <option value="KY">Kentucky</option> <option value="LA">Louisiana</option> <option value="ME">Maine</option> <option value="MD">Maryland</option> <option value="MA">Massachusetts</option> <option value="MI">Michigan</option> <option value="MN">Minnesota</option> <option value="MS">Mississippi</option> <option value="MO">Missouri</option> <option value="MT">Montana</option> <option value="NE">Nebraska</option> <option value="NV">Nevada</option> <option value="NH">New Hampshire</option> <option value="NJ">New Jersey</option> <option value="NM">New Mexico</option> <option value="NY">New York</option> <option value="NC">North Carolina</option> <option value="ND">North Dakota</option> <option value="MP">Northern Mariana Islands</option> <option value="OH">Ohio</option> <option value="OK">Oklahoma</option> <option value="OR">Oregon</option> <option value="PA">Pennsylvania</option> <option value="PR">Puerto Rico</option> <option value="RI">Rhode Island</option> <option value="SC">South Carolina</option> <option value="SD">South Dakota</option> <option value="TN">Tennessee</option> <option value="TX">Texas</option> <option value="VI">U.S. Virgin Islands</option> <option value="UT">Utah</option> <option value="VT">Vermont</option> <option value="VA">Virginia</option> <option value="WA">Washington</option> <option value="WV">West Virginia</option> <option value="WI">Wisconsin</option> <option value="WY">Wyoming</option> </select> </div> <div class="col-md-2 mb-1"> <label for="id_subject_set-0-business_zip_code" class="form-label">Zip code</label> <input type="text" name="subject_set-__prefix__-business_zip_code" class="form-control" maxlength="10" id="id_subject_set-__prefix__-business_zip_code"> </div> </div> <!-- business phones --> <div class="row mt-2 pb-3"> <div class="col-md-3 mb-1"> <label for="id_subject_set-0-business_phone" class="form-label">Business phone</label> <input type="text" name="subject_set-__prefix__-business_phone" class="form-control" maxlength="14" id="id_subject_set-__prefix__-business_phone"> </div> <div class="col-md-3 mb-1"> <label for="id_subject_set-0-business_cell_phone" class="form-label">Business cell phone</label> <input type="text" name="subject_set-__prefix__-business_cell_phone" class="form-control" maxlength="14" id="id_subject_set-__prefix__-business_cell_phone"> </div> </div> </div> <div id="subject_set-demographics-__prefix__" class="demoFraud"> <h5 class="mb-2 mt-2">Subject Demographics</h5> <label class="form-label">Please provide demographic information regarding the subject</label> <!-- subject demographics --> <div class="row"> <div class="col-md-3 mb-3"> <label for="id_subject_set-__prefix__-race" class="form-label">Race</label> <select name="subject_set-__prefix__-race" class="form-select" maxlength="20" id="id_subject_set-__prefix__-race"> <option value="" selected></option> <option value="asian">Asian</option> <option value="black">Black</option> <option value="hispanic">Hispanic</option> <option value="indian">NA Indian\Alaskan</option> <option value="other">Other</option> <option value="unknown">Unknown</option> <option value="white">White</option> </select> </div> <div class="col-md-3 mb-3"> <label for="id_subject_set-__prefix__-gender" class="form-label">Sex</label> <select name="subject_set-__prefix__-gender" class="form-select" maxlength="1" id="id_subject_set-__prefix__-gender"> <option value="" selected></option> <option value="M">Male</option> <option value="F">Female</option> </select> </div> <div class="col-md-3 mb-3"> <label for="inputSubjectDemoBirthDay" class="form-label">Birthday</label> <div class="input-group"> <input type="date" name="subject_set-__prefix__-birthday" class="form-control" id="id_subject_set-__prefix__-birthday"> </div> </div> <div class="col-md-2 mb-3"> <label for="id_subject_set-__prefix__-birth_state" class="form-label">State of Birth</label> <select name="subject_set-__prefix__-birth_state" class="form-select" maxlength="2" id="id_subject_set-__prefix__-birth_state"> <option value="" selected></option> <option value="AL">Alabama</option> <option value="AK">Alaska</option> <option value="AS">American Samoa</option> <option value="AZ">Arizona</option> <option value="AR">Arkansas</option> <option value="CA">California</option> <option value="CO">Colorado</option> <option value="CT">Connecticut</option> <option value="DE">Delaware</option> <option value="FL">Florida</option> <option value="GA">Georgia</option> <option value="GU">Guam</option> <option value="HI">Hawaii</option> <option value="ID">Idaho</option> <option value="IL">Illinois</option> <option value="IN">Indiana</option> <option value="IA">Iowa</option> <option value="KS">Kansas</option> <option value="KY">Kentucky</option> <option value="LA">Louisiana</option> <option value="ME">Maine</option> <option value="MD">Maryland</option> <option value="MA">Massachusetts</option> <option value="MI">Michigan</option> <option value="MN">Minnesota</option> <option value="MS">Mississippi</option> <option value="MO">Missouri</option> <option value="MT">Montana</option> <option value="NE">Nebraska</option> <option value="NV">Nevada</option> <option value="NH">New Hampshire</option> <option value="NJ">New Jersey</option> <option value="NM">New Mexico</option> <option value="NY">New York</option> <option value="NC">North Carolina</option> <option value="ND">North Dakota</option> <option value="MP">Northern Mariana Islands</option> <option value="OH">Ohio</option> <option value="OK">Oklahoma</option> <option value="OR">Oregon</option> <option value="PA">Pennsylvania</option> <option value="PR">Puerto Rico</option> <option value="RI">Rhode Island</option> <option value="SC">South Carolina</option> <option value="SD">South Dakota</option> <option value="TN">Tennessee</option> <option value="TX">Texas</option> <option value="VI">U.S. Virgin Islands</option> <option value="UT">Utah</option> <option value="VT">Vermont</option> <option value="VA">Virginia</option> <option value="WA">Washington</option> <option value="WV">West Virginia</option> <option value="WI">Wisconsin</option> <option value="WY">Wyoming</option> </select> </div> </div> </div> </div> </div> </div> <!-- <div class="bg-light ps-4 pb-4"> <button type="button" id="add-subject" class="btn btn-sm btn-outline-primary">report additional subjects</button> </div> --> <div class="bg-light p-4 mt-3 mb-1 pb-0"> <h5 class="mb-2">Victim Information</h5> <label class="form-label">Please tell us who was impacted by the fraud, waste, abuse</label> <div class="row mt-2"> <div class="col-md-4 mb-3"> <label for="id_victim-ssn" class="form-label m-0">Social Security Number</label> <div class="form-text">SSN will be kept confidential</div> <input type="password" name="victim-ssn" class="form-control" maxlength="11" id="id_victim-ssn"> </div> </div> <!-- victim info row 1--> <div class="row mt-2"> <div class="col-md-4 mb-3"> <label for="id_victim-first_name" class="form-label">First name</label> <input type="text" name="victim-first_name" class="form-control" maxlength="20" id="id_victim-first_name"> </div> <div class="col-md-3 mb-3"> <label for="id_victim-middle_name" class="form-label">Middle name</label> <input type="text" name="victim-middle_name" class="form-control" maxlength="20" id="id_victim-middle_name"> </div> <div class="col-md-4 mb-3"> <label for="id_victim-last_name" class="form-label">Last name</label> <input type="text" name="victim-last_name" class="form-control" maxlength="40" id="id_victim-last_name"> </div> <div class="col-md-1 mb-3"> <label for="id_victim-suffix" class="form-label">Suffix</label> <select name="victim-suffix" class="form-select" maxlength="25" id="id_victim-suffix"> <option value="" selected></option> <option value="Jr">Jr</option> <option value="Sr">Sr</option> <option value="I">I</option> <option value="II">II</option> <option value="III">III</option> <option value="IV">IV</option> <option value="V">V</option> </select> </div> </div> <!-- victim row 2 --> <div class="row"> <div class="col-md-6 mb-3"> <label for="id_victim-street" class="form-label">Street</label> <input type="text" name="victim-street" class="form-control" maxlength="100" id="id_victim-street"> </div> <div class="col-md-6 mb-3"> <label for="id_victim-building" class="form-label">Apartment, suite, building, etc...</label> <input type="text" name="victim-building" class="form-control" maxlength="100" id="id_victim-building"> </div> </div> <!-- victim info row 3 --> <div class="row mt-2"> <div class="col-md-4 mb-3"> <label for="id_victim-city" class="form-label">City</label> <input type="text" name="victim-city" class="form-control" maxlength="25" id="id_victim-city"> </div> <div class="col-md-2 mb-3"> <label for="id_victim-state" class="form-label">State</label> <select name="victim-state" class="form-select" maxlength="2" id="id_victim-state"> <option value="" selected></option> <option value="AL">Alabama</option> <option value="AK">Alaska</option> <option value="AS">American Samoa</option> <option value="AZ">Arizona</option> <option value="AR">Arkansas</option> <option value="CA">California</option> <option value="CO">Colorado</option> <option value="CT">Connecticut</option> <option value="DE">Delaware</option> <option value="FL">Florida</option> <option value="GA">Georgia</option> <option value="GU">Guam</option> <option value="HI">Hawaii</option> <option value="ID">Idaho</option> <option value="IL">Illinois</option> <option value="IN">Indiana</option> <option value="IA">Iowa</option> <option value="KS">Kansas</option> <option value="KY">Kentucky</option> <option value="LA">Louisiana</option> <option value="ME">Maine</option> <option value="MD">Maryland</option> <option value="MA">Massachusetts</option> <option value="MI">Michigan</option> <option value="MN">Minnesota</option> <option value="MS">Mississippi</option> <option value="MO">Missouri</option> <option value="MT">Montana</option> <option value="NE">Nebraska</option> <option value="NV">Nevada</option> <option value="NH">New Hampshire</option> <option value="NJ">New Jersey</option> <option value="NM">New Mexico</option> <option value="NY">New York</option> <option value="NC">North Carolina</option> <option value="ND">North Dakota</option> <option value="MP">Northern Mariana Islands</option> <option value="OH">Ohio</option> <option value="OK">Oklahoma</option> <option value="OR">Oregon</option> <option value="PA">Pennsylvania</option> <option value="PR">Puerto Rico</option> <option value="RI">Rhode Island</option> <option value="SC">South Carolina</option> <option value="SD">South Dakota</option> <option value="TN">Tennessee</option> <option value="TX">Texas</option> <option value="VI">U.S. Virgin Islands</option> <option value="UT">Utah</option> <option value="VT">Vermont</option> <option value="VA">Virginia</option> <option value="WA">Washington</option> <option value="WV">West Virginia</option> <option value="WI">Wisconsin</option> <option value="WY">Wyoming</option> </select> </div> <div class="col-md-2 mb-3"> <label for="id_victim-zip_code" class="form-label">Zip code</label> <input type="text" name="victim-zip_code" class="form-control" maxlength="10" id="id_victim-zip_code"> </div> </div> <!-- victim info row 4 --> <div class="row mt-2"> <div class="col-md-3 mb-3"> <label for="id_victim-phone_home" class="form-label">Home phone</label> <input type="text" name="victim-phone_home" class="form-control" maxlength="14" id="id_victim-phone_home"> </div> <div class="col-md-3 mb-3"> <label for="id_victim-phone_cell" class="form-label">Cell phone</label> <input type="text" name="victim-phone_cell" class="form-control" maxlength="14" id="id_victim-phone_cell"> </div> <div class="col-md-3 mb-3"> <label for="id_victim-phone_work" class="form-label">Work phone</label> <input type="text" name="victim-phone_work" class="form-control" maxlength="14" id="id_victim-phone_work"> </div> <div class="col-md-2 mb-3"> <label for="id_victim-phone_work_extension" class="form-label">Work extension</label> <input type="text" name="victim-phone_work_extension" class="form-control" maxlength="5" id="id_victim-phone_work_extension"> </div> </div> <h5 class="mb-2 mt-2">Victim Demographics</h5> <label class="form-label">Please provide demographic information regarding the victim</label> <!-- victim demographics --> <div class="row"> <div class="col-md-3 mb-3"> <label for="id_victim-race" class="form-label">Race</label> <select name="victim-race" class="form-select" maxlength="20" id="id_victim-race"> <option value="" selected></option> <option value="asian">Asian</option> <option value="black">Black</option> <option value="hispanic">Hispanic</option> <option value="indian">NA Indian\Alaskan</option> <option value="other">Other</option> <option value="unknown">Unknown</option> <option value="white">White</option> </select> </div> <div class="col-md-3 mb-3"> <label for="id_victim-gender" class="form-label">Sex</label> <select name="victim-gender" class="form-select" maxlength="1" id="id_victim-gender"> <option value="" selected></option> <option value="M">Male</option> <option value="F">Female</option> </select> </div> <div class="col-md-3 mb-3"> <label for="inputVictimDemoBirthDay" class="form-label">Birthday</label> <div class="input-group"> <input type="date" name="victim-birthday" class="form-control" id="id_victim-birthday"> </div> </div> </div> </div> <div class="bg-light p-4 mb-2 mt-3"> <h5 class="mb-2">Fraud Details</h5> <div class="col-md-12"> <label for="id_fraud_detail-description" class="form-label">Please describe the alleged fraud, waste, abuse</label> <span style="font-style: italic;">(Note: Copying and pasting text from external applications may result in errors)</span> <div id="fraud-char-counter" class="mb-2"></div> <textarea name="fraud_detail-description" cols="33" rows="7" class="form-control" maxlength="4000" id="id_fraud_detail-description"> </textarea> </div> </div> <div class="d-grid mb-3"> <button class="btn btn-primary btn-block" type="submit">Submit</button> </div> </form> </div> <!-- jquery --> <script type="text/javascript" src="/oig/static/js/jquery/jquery-3.7.1.min.js"></script> <!-- jquery UI (for datepicker) --> <!-- <script type="text/javascript" src="/static/js/jquery-ui-1.13.2/jquery-ui.min.js"></script> --> <!-- bootstrap js --> <script src="/oig/static/js/bootstrap/bootstrap.bundle.min.js"> </script> <!-- fraud reports custom js --> <script type="text/javascript" src="/oig/static/js/fraudreports/custom_fraud.js"></script> <!-- scam reports custom js --> <script type="text/javascript" src="/oig/static/js/scamreports/custom_scam.js"></script> </body> </html>