Benefit Payment Control (BPC) Fraud Detection and Prevention Unit

A. Your information

First Name

Last Name

Email Confirm

Telephone

B. Claimant Information (Fields marked with an asterisk(*) are required.)

Full Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Reason(s) you suspect they were involved in possible unemployment fraud. Be specific

Telephone

C. Business / Employer Information

Name of business or employer where this person is working:

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Telephone

How were they paid?

Cash

Check

Barter

Other

Please explain other

When did the person begin work?

What days and hours does this person work?

What type of work were they doing?

If this person was unable to work due to being in jail, on vacation, ill or injured, please give as much information as possible

D. If this person started a business, please provide:

Name of the business

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Business Telephone

Advertising information

Name of customer(s) who used this business and their address(es) and phone number(s)

Any other information proving the business exists

E. To report possible fraud by an employer

Business not registered with the state

Not reporting employees or wages to the state

Paying employees under the table

Other information that may be helpful to an investigation

Other Information

Other information or comments: (such as physical description, social networking site, i.e., facebook, type of car driven, etc.)

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