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