Fraud Reporting Form For Unemployment Insurance Benefits - Louisiana Workforce Commission
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2Fraud 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)
______________________________________________________
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