Form DOL-2915 "Reporting Suspected Unemployment Insurance Fraud and Identity Theft" - Georgia (United States)

What Is Form DOL-2915?

This is a legal form that was released by the Georgia Department of Labor - a government authority operating within Georgia (United States). As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2013;
  • The latest edition provided by the Georgia Department of Labor;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DOL-2915 by clicking the link below or browse more documents and templates provided by the Georgia Department of Labor.

ADVERTISEMENT
ADVERTISEMENT

Download Form DOL-2915 "Reporting Suspected Unemployment Insurance Fraud and Identity Theft" - Georgia (United States)

Download PDF

Fill PDF online

Rate (4.7 / 5) 16 votes
R
S
u
i
F
i
t
epoRting
uSpected
nemployment
nSuRance
Raud and
dentity
heFt
The Georgia Department of Labor (GDOL) is committed to preserving the integrity of the Unemployment Trust
Fund. Our department conducts many types of fraud and abuse investigations throughout the year on unemploy-
ment claims to ensure the accuracy of benefit payments made. Please provide as much information as possible.
The more detailed information you can provide, the better it will help us with our investigations. Fields marked
with an asterisk (*) are required.
S
A: Y
i
(o
)
ection
our
nformAtion
ptionAl
Prefer to remain anonymous?
If you want to anonymously report suspicious or illegal activity, avoid leaving any personal information, such as your
name and relationship to the individual you are reporting.
Your Name: _______________________________________ Relationship to the individual ________________
(First, MI, Last)
Your E-mail: _______________________________________ Phone number: _____ / _____ / ___________
S
B: S
i
ection
uSpect
S
nformAtion
* Name: ____________________________________________ SSN: (if known): ________________________
(First, MI, Last)
Street Address: ______________________________________ Phone number: _____ / _____ / ___________
City: _______________________________________________ State: __________ Zip: ____________________
DOB: _____ / _____ / ___________
* Fill in below the reason(s) you suspect the individual was involved in possible unemployment fraud and identity
theft. Be specific. Additional information may be furnished. Please attach separate sheets of paper if needed, and
include the individual’s full name on each sheet.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
_________________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
DOL-2915 (R-09/13)
1
R
S
u
i
F
i
t
epoRting
uSpected
nemployment
nSuRance
Raud and
dentity
heFt
The Georgia Department of Labor (GDOL) is committed to preserving the integrity of the Unemployment Trust
Fund. Our department conducts many types of fraud and abuse investigations throughout the year on unemploy-
ment claims to ensure the accuracy of benefit payments made. Please provide as much information as possible.
The more detailed information you can provide, the better it will help us with our investigations. Fields marked
with an asterisk (*) are required.
S
A: Y
i
(o
)
ection
our
nformAtion
ptionAl
Prefer to remain anonymous?
If you want to anonymously report suspicious or illegal activity, avoid leaving any personal information, such as your
name and relationship to the individual you are reporting.
Your Name: _______________________________________ Relationship to the individual ________________
(First, MI, Last)
Your E-mail: _______________________________________ Phone number: _____ / _____ / ___________
S
B: S
i
ection
uSpect
S
nformAtion
* Name: ____________________________________________ SSN: (if known): ________________________
(First, MI, Last)
Street Address: ______________________________________ Phone number: _____ / _____ / ___________
City: _______________________________________________ State: __________ Zip: ____________________
DOB: _____ / _____ / ___________
* Fill in below the reason(s) you suspect the individual was involved in possible unemployment fraud and identity
theft. Be specific. Additional information may be furnished. Please attach separate sheets of paper if needed, and
include the individual’s full name on each sheet.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
_________________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
DOL-2915 (R-09/13)
1
R
S
u
i
F
i
t
epoRting
uSpected
nemployment
nSuRance
Raud and
dentity
heFt
S
c: i
t
i
ection
dentifY
heft
nformAtion
Please complete this section if someone is using your social security number (SSN) or you are aware of some-
one using another individual’s SSN to file a fraudulent UI claim and/or receiving UI benefits. You should also file
a police report and notify the Federal Trade Commission either online at http://ftc.gov/idtheft or by phone at
1.877.438.4338. The following information should be provided to GDOL to assist in the investigation. If this sec-
tion does not apply proceed to Section D.
What is the SSN being used: ________-_______-_______
Is your SSN being used to file a fraudulent UI claim and/or receive UI benefits? YES _____ NO _____
Are you aware of someone using another individual’s SSN to file a fraudulent UI claim and/or receive UI benefits?
YES ______ NO _____
Is this individual using your name to file a fraudulent UI claim and/or receiving UI benefits?
YES ______ NO _____
If no, what name is being used? ___________________________________________________________
Have you filed a report with your local police department? YES _____ NO _____
If yes, in which state was the report filed?___________-_____ Police Report Number: _______________
Is an investigation being conducted: YES _____ NO _____
Please provide a statement below regarding the incident that led to the identity being stolen:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
_________________________________________________________________________________________________
S
d: e
i
ection
mploYment
nformAtion
If you suspect someone is working and using a fraudulent social security number (SSN), please complete this sec-
tion. If this section does not apply, proceed to Section E.
Is your SSN being fraudulently used for employment purposes? YES ______ NO _____
Are you aware of someone using another individual’s SSN for employment purposes? YES ______ NO _____
Name and address of employer/business where the individual is working:
Name: _____________________________________________________________________________________
(Business/Employer Name)
Street Address: _______________________________________ Phone: ________-________-___
DOL-2915 (R-09/13)
2
R
S
u
i
F
i
t
epoRting
uSpected
nemployment
nSuRance
Raud and
dentity
heFt
City:_____________________________________________ State:___________ Zip: _______________________
Name of contact person at this business____________________________________________________________
(First, MI, Last)
What type of work is this individual performing?______________________________________________________
How is the individual paid? o Cash o Check o Barter o Other_______________________________________
When did the individual begin work? ______________________________________________________________
(MM/DD/YY)
What days and hours does the individual work? ______________________________________________________
What name is the individual working under? ________________________________________________________
(First, MI, Last)
Have you filed a report with your local police department? YES _____ NO _____
If yes, in which state was the report filed?_________________ Police Report Number: ______________
Is an investigation being conducted: YES _____ NO _____
Please provide a statement below regarding the incident that led to the identity being stolen:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
________________________________________________________________________________________________
S
d: o
i
ection
ther
nformAtion
Other additional information or comments you would like to provide:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
________________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
DOL-2915 (R-09/13)
3
R
S
u
i
F
i
t
epoRting
uSpected
nemployment
nSuRance
Raud and
dentity
heFt
Section E: How to submit Information
Please mail or fax this form and any additional documents to:
Georgia Department of Labor
UI Integrity Unit; Suite 727
148 Andrew Young International Blvd
Atlanta, GA 30303-1732
Fax: 404.232.3445
The Georgia Department of Labor considers the information you provide to be confidential and will
protect the identity of the person reporting fraud and/or identity theft. Thank you for assisting in the
prevention of Unemployment Insurance fraud and/or identity theft.
DOL-2915 (R-09/13)
4