Request for Investigation of Unemployment Insurance Fraud Instructions
This form contains 42 fields organized into 11 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Additional Information | ||
| Additional Information | Text |
Please provide any additional relevant information in this field.
|
| Employment Details | ||
| Business Phone Number | Text |
Enter the phone number of the business where the person is employed. Fill only if 'Employed and Filing for Unemployment Benefits' is 'Yes'.
Depends on:
Employed and Filing for Unemployment Benefits
|
| Business Name | Text |
Enter the full legal name of the business where the person is employed. Fill only if 'Employed and Filing for Unemployment Benefits' is 'Yes'.
Depends on:
Employed and Filing for Unemployment Benefits
|
| Business Address | Text |
Enter the complete address of the business where the person is employed. Fill only if 'Employed and Filing for Unemployment Benefits' is 'Yes'.
Depends on:
Employed and Filing for Unemployment Benefits
|
| First Day of Work | Date |
Enter the approximate first day the person started working at this business. Fill only if 'Employed and Filing for Unemployment Benefits' is 'Yes'.
Depends on:
Employed and Filing for Unemployment Benefits
|
| Out of state or country: Working | Checkbox |
Check this box if the person receiving unemployment benefits is out of state or country because they are working. Fill only if 'Out of state or country' is 'Yes'.
Depends on:
Out of state or country
|
| Out of state or country: Vacation / Personal Business | Checkbox |
Check this box if the person receiving unemployment benefits is out of state or country for vacation or personal business reasons. Fill only if 'Out of state or country' is 'Yes'.
Depends on:
Out of state or country
|
| In School | Checkbox |
Check this box if the person receiving unemployment benefits is currently in school.
|
| Other Status | Checkbox |
Check this box if the person's current situation or status is not described by any other option in the 'This person is' section.
|
| I wish to remain anonymous: Yes | Checkbox |
Check this box if you wish to remain anonymous when submitting the fraud investigation request.
|
| General | ||
| Additional Information - Line 1 | Text | |
| Additional Information - Line 2 | Text | |
| Additional Information - Line 3 | Text | |
| Additional Information - Line 4 | Text | |
| Incarceration Details | ||
| Name of Institution | Text |
Please provide the name of the institution where the person is incarcerated. Fill only if 'Incarcerated / Jail' is 'Yes'.
Depends on:
Incarcerated / Jail
|
| Date of Incarceration | Date |
Please provide the date when the person was incarcerated. Fill only if 'Incarcerated / Jail' is 'Yes'.
Depends on:
Incarcerated / Jail
|
| Other Reason | ||
| Other Reason Description | Text |
Please provide a detailed description for the 'Other' reason not covered by the preceding categories. Fill only if 'Other Status' is 'Yes'.
Depends on:
Other Status
|
| Out of State/Country Details | ||
| Location Address Out of State/Country | Text |
Please provide the location or address where the person was out of state or country. Fill only if 'Out of state or country' is 'Yes'.
Depends on:
Out of state or country
|
| Dates Out of State/Country | Date |
Please provide the dates when the person was out of state or country for the specified reason. Fill only if 'Out of state or country' is 'Yes'.
Depends on:
Out of state or country
|
| Person Receiving Unemployment Benefits | ||
| Person's Name | Text |
Please provide the full name of the person receiving unemployment benefits.
|
| Social Security Number | Text |
Please enter the Social Security Number of the person receiving unemployment benefits, if known.
|
| Street Address | Text |
Please provide the street address of the person receiving unemployment benefits.
|
| City, State, Zip | Text |
Please enter the city, state, and zip code for the person receiving unemployment benefits.
|
| Phone Number | Text |
Please provide the phone number of the person receiving unemployment benefits.
|
| Employed and Filing for Unemployment Benefits | Checkbox |
Check this box if the person is currently employed and filing for unemployment benefits.
|
| Self-Employed | Checkbox |
Check this box if the person is self-employed.
|
| Incarcerated / Jail | Checkbox |
Check this box if the person receiving unemployment benefits is currently incarcerated or held in jail.
|
| Not Able and Available for Work | Checkbox |
Check this box if the person is not able and available for work.
|
| Out of state or country | Checkbox |
Check this box if the person receiving unemployment benefits is located outside their state or country of residence.
|
| School Attendance Details | ||
| School Location | Text |
Provide the name and address of the school the person is attending. Fill only if 'In School' is 'Yes'.
Depends on:
In School
|
| School Attendance Dates | Text |
Provide the dates during which the person attended or is attending school. Fill only if 'In School' is 'Yes'.
Depends on:
In School
|
| Self-Employment Details | ||
| Company Name | Text |
Provide the full legal name of the self-employed company. Fill only if 'Self-Employed' is 'Yes'.
Depends on:
Self-Employed
|
| Company Phone Number | Text |
Enter the primary phone number for the self-employed company. Fill only if 'Self-Employed' is 'Yes'.
Depends on:
Self-Employed
|
| Company Address | Text |
Provide the full street address of the self-employed company. Fill only if 'Self-Employed' is 'Yes'.
Depends on:
Self-Employed
|
| Company Website Address | Text |
Enter the website address for the self-employed company. Fill only if 'Self-Employed' is 'Yes'.
Depends on:
Self-Employed
|
| Self-Employment Start Date | Date |
Provide the date when the self-employment began. Fill only if 'Self-Employed' is 'Yes'.
Depends on:
Self-Employed
|
| I wish to remain anonymous: No | Checkbox |
Check this box if you do not wish to remain anonymous and are willing to provide your identity for the fraud investigation request.
|
| Submitter Information | ||
| Submitter Name | Text |
Please provide your full name. Fill only if 'I wish to remain anonymous: No' is 'Yes'.
Depends on:
I wish to remain anonymous: No
|
| Submitter Phone Number | Text |
Please provide your phone number. Fill only if 'I wish to remain anonymous: No' is 'Yes'.
Depends on:
I wish to remain anonymous: No
|
| Relationship to Beneficiary | Text |
Please describe your relationship with the person receiving unemployment insurance. Fill only if 'I wish to remain anonymous: No' is 'Yes'.
Depends on:
I wish to remain anonymous: No
|
| Work Unavailability Details | ||
| Reason for Unavailability | Text |
Please provide the reason why the person is not able and available for work, such as illness or other factors. Fill only if 'Not Able and Available for Work' is 'Yes'.
Depends on:
Not Able and Available for Work
|
| Date of Restriction | Date |
Please provide the date when the restriction for work unavailability began or applies. Fill only if 'Not Able and Available for Work' is 'Yes'.
Depends on:
Not Able and Available for Work
|