Request For Investigation Of Unemployment Insurance
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1DLLR
DIVISION OF UNEMPLOYMENT INSURANCE
1100 North Eutaw Street
Baltimore, MD 21201
REQUEST FOR INVESTIGATION OF UNEMPLOYMENT INSURANCE FRAUD
Mail to: Benefit Payment Control, Room 206, 1100 North Eutaw Street, Baltimore, MD 21201 or Fax to 410-767-2610
_______________________________________________________________
_______________________________
Person receiving Unemployment Benefits
Social Security Number (if known)
_______________________________________________________________
_______________________________
Street Address
City, State, Zip
Phone
This person is: (check all that apply and complete)
____ Employed and filing for Unemployment Benefits
Name of Business ______________________________________
Phone _________________________
Address _________________________________________________________________________________
First day of work (approximate) ______________________________________________________________
____ Self-Employed
Name of Company _____________________________________
Phone _________________________
Address _________________________________________________________________________________
Website address ________________________
When did he/she start working? _____________________
____ Incarcerated / Jail
Name of Institution _____________________________________
Date of Incarceration ______________
____ Not able and available for work
Reason (i.e. illness, etc.) ____________________________________________________________________
Date of restriction _________________________________________________________________________
____ Out of state or country
Where (location/address) ___________________________________________________________________
Reason: Working _____ , Vacation / personal business _____,
Dates __________________________
____ In school
Where ________________________________________________
Dates of attendance _______________
____ Other
_______________________________________________________________________________________
_______________________________________________________________________________________
Please provide any additional information available: ___________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Your Name: ________________________________________________
Phone _________________________
What is your relationship with the person receiving unemployment insurance? ___________________________________
I wish to remain anonymous Yes _____
No _____
(Note: You may remain anonymous, but it is important that the investigator is able to contact you for additional information.)
•
•
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P
: 410-767-2404
F
: 410-767-2610
e
: uifraud@dllr.state.md.us
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