"Fraud Reporting Form for Unemployment Insurance Benefits" - Louisiana

Fraud Reporting Form for Unemployment Insurance Benefits is a legal document that was released by the Louisiana Workforce Commission - a government authority operating within Louisiana.

Form Details:

  • Released on April 1, 2011;
  • The latest edition currently provided by the Louisiana Workforce Commission;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Louisiana Workforce Commission.

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Fraud Reporting Form for Unemployment Insurance Benefits
Rev 04/11
UI Benefit Fraud is defined as:
Any willful misrepresentation or willful concealment of material facts by an
individual to obtain or increase benefits or thereby the receipt of any benefits to
which a claimant was not entitled.
If someone you know has committed fraud, as defined above, to obtain unemployment
benefits, please provide all of the following information that you have available to you.
Information About the Claimant (Person Committing Fraud):
Claimant’s Name _______________________________________________
Social Security Number _______________
Address: Street _________________________________________________
City _________________________________________________
State ___________________ Zip Code ____________________
Home Phone Number including Area Code ________________
Cell Phone Number including Area Code _________________
Drivers License Number ________________________ State _____________
Description of Claimant:
“X” Sex of Claimant
__ Male __ Female
Race ___________________
Approximate: Age ________ Height ________ Weight ______ lbs.
Eye Color ________________ Eye Glasses: __ Yes __ No
Hair Color _______________
Distinguishing features/marks/traits: __________________________________
________________________________________________________
Claimant’s Vehicle Description:
Make ___________________ Model _________________________
Year ___________________ Color _________________________
License Plate Number ___________________________ State ______
“X” as many as apply to provide reasons claimant is not entitled to UI benefits:
__ Claimant is Not Actively Searching for Work
__ Already Employed / Not Reporting Earnings
Name of Employer __________________________________________
Name of Contact Person at this Business _________________________
Employer’s Address: Street __________________________________
City __________________________________
State ______________ Zip ________________
Employer’s Phone # _________________
Claimant’s Job Title (or type of work claimant performs for this employer)
______________________________________________________
Fraud Reporting Form for Unemployment Insurance Benefits
Rev 04/11
UI Benefit Fraud is defined as:
Any willful misrepresentation or willful concealment of material facts by an
individual to obtain or increase benefits or thereby the receipt of any benefits to
which a claimant was not entitled.
If someone you know has committed fraud, as defined above, to obtain unemployment
benefits, please provide all of the following information that you have available to you.
Information About the Claimant (Person Committing Fraud):
Claimant’s Name _______________________________________________
Social Security Number _______________
Address: Street _________________________________________________
City _________________________________________________
State ___________________ Zip Code ____________________
Home Phone Number including Area Code ________________
Cell Phone Number including Area Code _________________
Drivers License Number ________________________ State _____________
Description of Claimant:
“X” Sex of Claimant
__ Male __ Female
Race ___________________
Approximate: Age ________ Height ________ Weight ______ lbs.
Eye Color ________________ Eye Glasses: __ Yes __ No
Hair Color _______________
Distinguishing features/marks/traits: __________________________________
________________________________________________________
Claimant’s Vehicle Description:
Make ___________________ Model _________________________
Year ___________________ Color _________________________
License Plate Number ___________________________ State ______
“X” as many as apply to provide reasons claimant is not entitled to UI benefits:
__ Claimant is Not Actively Searching for Work
__ Already Employed / Not Reporting Earnings
Name of Employer __________________________________________
Name of Contact Person at this Business _________________________
Employer’s Address: Street __________________________________
City __________________________________
State ______________ Zip ________________
Employer’s Phone # _________________
Claimant’s Job Title (or type of work claimant performs for this employer)
______________________________________________________
Amount of Salary/Earnings $ ___________
Hours Worked/Days Worked ___________________________________
Does the claimant wear a company uniform for the job? _____
Does the claimant drive a company vehicle for the job? _____
Is the claimant being paid cash rather than a company payroll check? ____
__ Claimant is Not Able to Work / Not Available for Work
Why Not?:
__ Ill - Type of Medical Problem ______________________________
When?/Since what period of time?_______________________
__ Hospitalized What Hospital? Where? _________________________
When? ____________________________________________
__ Disabled - Type of Disability _______________________________
When? ____________________________________________
__ Incarcerated (Jail/Prison) Where? ____________________________
When? ___________________________________________
__ Vacationing or Pursuing Hobby (Hunting/Fishing trip, etc.) Where ?
______________________ When?_____________________
__ No Transportation/Transportation Problems – When?______________
__ Full-time caretaker (for child/elder parent, etc. – For Whom?________
____________ Address ___________ City _________ State______
When?_________________________________________________
__ Other: Why?______________________________________________
When? _____________________________________________
__ Other - By what other method is the claimant committing fraud and when
did this fraudulent activity occur? ____________________________
_______________________________________________________
_______________________________________________________
Optional: In case of need for clarification or additional information, if we may contact
you concerning the information you provided, please complete the following:
Your Name __________________________________
Your Address ________________________________
City ____________________________
State ___________ Zip _____________
Your Phone Number ___________________
Additional Information /Comments: ________________________________________
_______________________________________________________________________
_______________________________________________________________________
Thank you for your assistance in enforcing the Louisiana Employment Security Law, and protecting
the integrity of the Louisiana Workforce Commission Unemployment Insurance Benefits Program.
*Fax to (225) 219-4712, or mail to Louisiana Workforce Commission,
*
Attention: Benefit Payment Control Unit, P.O. Box 44063,
Baton Rouge, LA 70804
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