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Request to Report Possible UI Fraud Violations

Help us do as thorough an investigation as possible - provide as much information as you can. Please use the "Additional Information" box if more space is needed. When you are finished, click the "Submit" button located at the bottom of this page.

Person you are reporting.

Name

SSN

Address

City

State

Zip

Phone Number

This Person Should Be Investigated for the Following Reason(s): Check all of the items below that apply and then fill in as much information as you can.

The individual is self-employed

Business Name

Address

City

State

Zip

Phone

Business License

Date Started

The individual is working and may not be reporting accurately

Employer Name

Address

City

State

Zip

Phone

Job Title

Date Started

Works

Full-Time Available

How paid

Professional License

The individual is in jail

Jail Name

Incarceration Date

Release Date

The individual is unable to work (hospitalized or in rehabilitation)

Facility Name

Address / Phone

Reason

Date Admitted

The individual is injured or ill and unable to work

Injury Description

Date

The individual is not looking for work

Reason

The individual is in school

School Name

Date Started

The individual is out of area

Out of Area Reason

Area Relocated To

Date Left Area

The individual may be the victim of ID Theft

The individual refused an offer of work

Employer Name

Address

City

State

Zip

Phone

Offer Date

Start Date

Type of Work

Rate of Pay Offered

Job Position Offered

Name of Person Who Offered Job

Date of Refusal

This individual failed to properly apply for work or attend an interview

Employer Name

Address

City

State

Zip

Phone

Type of Work

Job Title

Rate of Pay

Date of Interview

Date Accepting Applications for the Position

Date Accepting Applications Ended

Reason did not Apply/Attend Interview

Additional Information Please provide additional information

Additional Information

0/2000

Your Information

Your Name

Phone Number

Do you wish to remain anonymous?

You may remain anonymous even if you provide your name and telephone number. This information will be available to the investigator only and will not be part of the file. It is helpful to the investigation if you can be reached for questions.

Yes No

Please correct the following item(s)

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