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Reporting Potential Unemployment Insurance Fraud

 

 

Note: Providing your name, phone number, and e-mail address are optional, but very helpful. You may remain anonymous by not completing these items.
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1.   Name    (Type Answer)
 
(100 character limit; 100 remaining.)
 
2.   Telephone number (Example: 999-111-0000)
  Ext:
 
3.   E-mail address    (Type Answer)
 
(100 character limit; 100 remaining.)
 

Please provide information on the potential fraudulent case below

 

 

To enable us to adequately investigate your allegation, be sure to include as much information as possible. If you do not know the answer to a specific question, just provide the information you do know.

 
4.   Name of the individual committing fraud    (Type Answer)
 
(100 character limit; 100 remaining.)
 
5.   Address
 
Address Line 1:
Address Line 2:
City / State / Zip:

6.   Telephone number (if known) (Example: 999-111-0000)
  Ext:
 

If you suspect or have information that this individual is working, please answer the following questions

 
 
7.   Name of business or employer    (Type Answer)
 
(100 character limit; 100 remaining.)
 
8.   Business Address
 
Address Line 1:
Address Line 2:
City / State / Zip:

9.   Employer’s telephone number (if known) (Example: 999-111-0000)
  Ext:
 
10.   When did the individual start work (Example: MM/DD/YYYY)
 
 
11.   What type of work is the individual doing?    (Type Answer)
 
(500 character limit; 500 remaining.)
 
12.   What days and hours does the individual work?    (Type Answer)
 
(500 character limit; 500 remaining.)
 
13.   How is the individual being paid?    (Select one)
  Cash    Check    Payment in Kind    Other   
 
14.   If other, please explain    (Type Answer)
 
(500 character limit; 500 remaining.)
 
15.   Is the employer assisting the individual to commit fraud?    (Select one)
  Yes    No   
 
16.   If the individual is not able to work due to being ill, in jail, on vacation, or otherwise unable to work, please provide as much information as possible (When did this happen? What is the nature of their restriction?)    (Type Answer)
 
(500 character limit; 500 remaining.)
 
17.   Additional information or comments    (Type Answer)
 
(500 character limit; 500 remaining.)
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