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Benefit Payment Control (BPC) Fraud Detection and Prevention Unit
You must have JavaScript enabled to use this form.
A. Your information
First Name
Last Name
Email
Email
Email Confirm
Telephone
B. Claimant Information (Fields marked with an asterisk(*) are required.)
Full Name
Claimant Address
Address
Address 2
City/Town
State/Province
- None -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East)
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federate States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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:
Business/Employer Address
Address
Address 2
City/Town
State/Province
- None -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East)
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federate States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
Started Business Address
Address
Address 2
City/Town
State/Province
- None -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East)
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federate States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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.)
Submit