Form BPC104F "Fraud Reporting Form" - Illinois

What Is Form BPC104F?

This is a legal form that was released by the Illinois Department of Employment Security - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2011;
  • The latest edition provided by the Illinois Department of Employment Security;
  • 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 fillable version of Form BPC104F by clicking the link below or browse more documents and templates provided by the Illinois Department of Employment Security.

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Download Form BPC104F "Fraud Reporting Form" - Illinois

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State of Illinois
Department of Employment Security
www.ides.illinois.gov
Fraud Reporting Form
Please provide as much of the following information as you can about the person you suspect is committing Unemployment
Insurance fraud. If you have additional information or concerns, call Benefit Payment Control at (312) 793-3200.
What leads you to believe the person is committing fraud?
Last Name:
First Name:
MI:
Also known as:
Social Security Number:
Gender:
Female
Male
Street address or P.O. Box:
City:
State:
Zip Code:
Telephone Number (Include area code: (
)
-
Email Address:
Date of Birth:
/
/
Approximate Age:
Does the person use an additional address or P.O. Box to receive mail other than the address listed above?
Yes
No
If yes, provide the different address:
When did the person begin collecting benefits?
Is the person still collecting benefits?
Yes
No
If not, when did the person stop collecting benefits?
Please provide employer information below, if the person is working and collecting benefits:
Address or P.O. Box:
Employer Name:
City:
State:
Zip Code:
Telephone Number: (
)
-
Type of work:
How is the worker paid?
Cash
Personal Check
Payroll Check
Combination
Other
If other, or a combination, please explain:
Is there any additional information you would like to provide?
Can we contact you? We will not identify you, if you want to remain anonymous.
Your Name:
MI.:
Last Name:
Street address or P.O. Box:
City:
State:
Zip Code:
Telephone Number: (
)
-
Email Address:
Print
BPC104F
Page 1 of 1 Page
Rev. (09/2011)
Print
Save
Clear
State of Illinois
Department of Employment Security
www.ides.illinois.gov
Fraud Reporting Form
Please provide as much of the following information as you can about the person you suspect is committing Unemployment
Insurance fraud. If you have additional information or concerns, call Benefit Payment Control at (312) 793-3200.
What leads you to believe the person is committing fraud?
Last Name:
First Name:
MI:
Also known as:
Social Security Number:
Gender:
Female
Male
Street address or P.O. Box:
City:
State:
Zip Code:
Telephone Number (Include area code: (
)
-
Email Address:
Date of Birth:
/
/
Approximate Age:
Does the person use an additional address or P.O. Box to receive mail other than the address listed above?
Yes
No
If yes, provide the different address:
When did the person begin collecting benefits?
Is the person still collecting benefits?
Yes
No
If not, when did the person stop collecting benefits?
Please provide employer information below, if the person is working and collecting benefits:
Address or P.O. Box:
Employer Name:
City:
State:
Zip Code:
Telephone Number: (
)
-
Type of work:
How is the worker paid?
Cash
Personal Check
Payroll Check
Combination
Other
If other, or a combination, please explain:
Is there any additional information you would like to provide?
Can we contact you? We will not identify you, if you want to remain anonymous.
Your Name:
MI.:
Last Name:
Street address or P.O. Box:
City:
State:
Zip Code:
Telephone Number: (
)
-
Email Address:
Print
BPC104F
Page 1 of 1 Page
Rev. (09/2011)