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Please use this form to report an individual committing fraud against the Pennsylvania Unemployment Compensation program.
Contact Information
Please provide your contact information.
First Name Last Name
Phone Email
Relationship to Claimant Would you prefer to remain anonymous?
Note: This information will remain confidential. You will only be contacted if additional information is needed.
Claimant Identification Information
Please supply as much of the following information as you can regarding the person committing fraud.
First Name Middle Initial
Last Name SSN
Date of Birth Phone
Address1 Address2
City State
ZIP County
Reporting Issue(s)
Please select the type(s) of issue(s) you wish to report. You may select more than one.







Able and Available
Since what date?
Description
Since what date? Name and/ or location
Address1 Address2
City State
ZIP
Since what date?
Name of Family Member Relationship to Claimant
Address1 Address2
City State
ZIP
Since what date? Name of School
Address1 Address2
City State
ZIP
Since what date? Location
Address1 Address2
City State
ZIP
Deceased Individual Information
First Name Middle Initial
Last Name SSN
Date of Birth Date of Death
Incarcerated
Name of the Facility Address1
Address2 City
State ZIP
Date of Incarceration Date of Release
Refusal of Work
Has this person refused an offer of full-time employment?
Name of business or individual offering employment
Telephone number of business or individual offering employment
Address1 Address2
City State
ZIP
Has this person restricted their work hours at their present employment in order to continue to receive higher benefits?
When?
Name of current employer
Telephone number of current employer
Address1 Address2
City State
ZIP
Self Employed
When? Name of Business
Address1 Address2
City State
ZIP Telephone Number
Type of Business How does the business advertise?
Do you have business customers' and/or suppliers' information?
Name of customers and/or suppliers Telephone Number
Address1 Address2
City State
ZIP
Separation
Did this individual voluntarily quit employment or was fired?
When? Name of Business
Address1 Address2
City State
ZIP Telephone Number
Unreported Earnings
Name of Employer Telephone Number
Address1 Address2
City State
ZIP
What type of work is the person doing?
Are they still working?
Is this person working for a family member or friend?
Relationship
When did they begin the work?
How are they being paid?
What days and hours do they work?

Where is their work location, if different than the employer's address?
Address1 Address2
City State
ZIP
Other
Other
Additional Documentation
Do you have additional documentation that can be provided upon request?
Due to strict confidentiality laws, the Department of Labor and Industry cannot confirm or deny an investigation initiated by the submission of this form nor can updates or outcomes be disclosed.

We will review the necessary files and records in light of the information you have provided to determine the most appropriate action. If you provided information about yourself, you will be contacted again only if it is necessary to complete our investigation.

Thank you for assisting in our effort to fight fraud, waste and abuse.

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