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Hide - Report Fraud
Unemployment Claim Fraud Questionnaire
Use this form to report fraud by someone collecting a UC benefit.
You are on page 1 of 1. There are 24 questions to answer on this page.
Your personal information is optional, but would enable an investigator to contact you if additional information is needed. If you provide your name and telephone number, and wish to remain anonymous, your identity will not be disclosed unless legally required.
Your Telephone Number:
Would you prefer to remain anonymous?
Do you wish to be contacted by an investigator?
Please supply as much of the following information as you can:
Full Name of Person Committing Fraud:
What is this person doing to defraud the unemployment compensation system?
Name of Employer Person is Working For:
Address of Employer:
How is person being paid?
When did the person begin work?
What days and hours do they work?
What type of work is the person doing?
If the person was in jail, on vacation or unable to work due to illness or injury, please give as much information as possible:
If person started a business, please provide the following information:
Name of Business:
Address of Business:
Telephone Number of Business:
Type/Nature of Business:
How the Business Advertises:
Names, addresses, telephone numbers of business’s customers:
Any other information we may use to prove the business exists?
Department of Labor & Industry
Commonwealth of Pennsylvania. All Rights Reserved
DATE/TIME:Dec 4, 2013 4:27:38 PM