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APPENDIX R

WITNESS NARRATIVE REPORT

Date of Incident: _________________________________________________ (if known)

Date of this form was prepared: _ _ _ _ _ _ _ _ _

Name of Person preparing this statement: (Please print)

Name of applicant suspected of fraud: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Please complete the statements below: I became aware of the incident when:

After being notified, I took the following actions:

I heard the applicant make the following statement(s):

I (circle one) I (circle one)

observed observed

did not observe did not observe

the applicant sign all the required forms.

the intake worker, _ _ _ _ _ _ _ _ _ _ _

Explain the potential for prosecution under US Title18 to the applicant.

Signed: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date:: _ _ _ _ _ _ _ _ _

Effective: April 1, 2026