"Fraud Reporting Form" - Wyoming

Fraud Reporting Form is a legal document that was released by the Wyoming Department of Workforce Services - a government authority operating within Wyoming.

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Wyoming Unemployment Insurance Division
Benefit Payment Control
Fraud Reporting Form
Date
Unemployment Insurance (UI) benefit fraud is any willful misrepresentation, omission or
concealment of material facts by an individual to obtain or increase benefits.
Please complete as much of the following information as possible about the person (claimant)
you believe is receiving UI benefits: Call (307) 235-3236 if you have questions or concerns.
Claimant’s Name:
Social Security Number (if known):
Address:
Street
City
State
Zip
Home Phone Number:
Cell Phone Number:
Mark an “X” for each issue that applies.
Claimant is working and NOT reporting earnings
Name of Employer:
Contact person at this business:
Employer’s Address: Street
City
State
Zip
Employer’s Phone Number:
Did you see the claimant working?
When?
Where?
Amount of Salary/Earnings:
Hours Worked/Days Worked per Week:
Date Claimant Started Working:
Is he/she still working?
Claimants Job Title (or type of work performed for this employer):
Claimant is self - employed
Name of business
What type of business or work is it?
Does the claimant advertise?
Claimant is NOT Actively Searching for work
Has the claimant told you he/she is not looking for work?
For what time period were they not seeking?
Claimant has refused work
For what business or individual?
Business or individual phone number or address
When?
Wyoming Unemployment Insurance Division
Benefit Payment Control
Fraud Reporting Form
Date
Unemployment Insurance (UI) benefit fraud is any willful misrepresentation, omission or
concealment of material facts by an individual to obtain or increase benefits.
Please complete as much of the following information as possible about the person (claimant)
you believe is receiving UI benefits: Call (307) 235-3236 if you have questions or concerns.
Claimant’s Name:
Social Security Number (if known):
Address:
Street
City
State
Zip
Home Phone Number:
Cell Phone Number:
Mark an “X” for each issue that applies.
Claimant is working and NOT reporting earnings
Name of Employer:
Contact person at this business:
Employer’s Address: Street
City
State
Zip
Employer’s Phone Number:
Did you see the claimant working?
When?
Where?
Amount of Salary/Earnings:
Hours Worked/Days Worked per Week:
Date Claimant Started Working:
Is he/she still working?
Claimants Job Title (or type of work performed for this employer):
Claimant is self - employed
Name of business
What type of business or work is it?
Does the claimant advertise?
Claimant is NOT Actively Searching for work
Has the claimant told you he/she is not looking for work?
For what time period were they not seeking?
Claimant has refused work
For what business or individual?
Business or individual phone number or address
When?
Wyoming Unemployment Insurance Division
Benefit Payment Control
Fraud Reporting Form
Page 2
Date
Claimant’s Name:
Claimant is NOT able to work or NOT Available for work
If Illness or Medical Problem, what type?
Since when
If Hospitalized, Where?
When?
Disabled - type of disability
Since When
Incarcerated (Jail/Prison) Where?
Jail contact or phone number
Date incarcerated
Date released
Vacationing or Pursuing Hobby (Hunting/Fishing trip, etc)
Where?
When?
No Transportation / Transportation Problems - When?:
Full time caretaker (for child/parents, etc.) For Whom?:
When?
Other:
Additional information/comments:
OPTIONAL: You will remain anonymous. Please complete the following if we can contact
you for clarification or additional information.
Your name
Your address
City
State
Your phone number
Submit by mailing to:
Wyoming Department of Workforce Services
Unemployment Insurance Division - BPC
PO Box 2760
Casper WY 82602-2760
Or fax to:
307-235-3277 ATTN: BPC
Thank you for your assistance in enforcing Wyoming Unemployment Insurance Division’s laws
and protecting the integrity of the Wyoming Unemployment Insurance program.
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