Report Unemployment Insurance Fraud

This form is to report unemployment insurance (UI) fraud against the Department of Labor and/or identity theft related to UI. The information you provide in this form will remain confidential. If you are reporting an individual or business for fraud, you may remain anonymous. However, we would like to contact you if we need more information. Thank you for helping us fight fraud.

* Indicates required fields

Please fill out this form to the best of your ability.

Are you reporting UI fraud that is related to identity theft, including someone filing a false claim using your personal information? *

Yes No

What is the type of fraud you are reporting? *

Person working while collecting UI benefits Person falsely reporting he or she is available for work
(but is actually injured or sick, on vacation, out of the country, in school, etc.) Person falsely reporting he or she is searching for work while collecting UI benefits Person falsely reporting reason for leaving prior job Person falsely reporting wages earned in last job Employer falsely reporting that employee was laid off Employer paying worker(s) "off the books" or "under the table" Other other

Please describe how the fraud is carried out*

You indicated that you may be a victim of identity theft related to unemployment insurance (UI), which is a type of UI fraud. Please answer all the following questions and submit your form. We will contact you as soon as we can. Note: This is a secure form and all information submitted will remain confidential.

Please describe the kind of identity theft you experienced.*

When did the fraud begin?*

Is the fraud still happening?*

Yes No I Don't Know

How did you learn about this fraud?*

Please include your contact information if you are willing to be contacted.

Please provide the following information:

Your Contact Information

Your First Name*

Your Last Name*

Your E-mail Address*

Your Phone Number*

( ) -

Your Address*

Address Line 1

Address Line 2

City*

State*

Zip*

Your Social Security Number*

- -

Please provide all information requested on this form. Your Social Security Number is required in order for the Department of Labor to determine whether a fraudulent claim has been filed in your name – we will not be able to process your complaint without it. All information provided on this form is strictly confidential and secure.

Please describe the business you believe is committing fraud.
Fill in as much information as you can.

Business

Business Name

Business Address

Business Address Line 1

Business Address Line 2

City

State

Zip

Business Phone Number

( ) -

Please describe the person you believe is committing fraud.
Fill in as much information as you can.

Person

Name of Person

Address

Address Line 1

Address Line 2

City

State

Zip

Phone Number

( ) -

Date of Birth

Gender

Male Female Other

Vehicle

Make

Model

State

License Plate Number

Describe the person's appearance (height, weight, hair length and color, skin color, eye color, etc.):

Where does the person work now?

Address of person's current employer

Address Line 1

Address Line 2

City

State

Zip

How long has the person worked there?

Owner/Principal name(s)

Type of business

Approximate number of employees

Other locations where work is performed (if different from main address)

Name of person's previous employer

How many years has the person been working there?