UC – Fraud Reporting System
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Benefits Fraud Form
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
Concerned Citizen
Co-Worker
Current Employer
Former Employer
Neighbor
Relative
Other
Would you prefer to remain anonymous?
Yes
No
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
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Washington DC
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
--- OTHER ---
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 - individual is not able and available to work
Deceased - individual passed away yet someone continues to file and collect benefits using the deceased person's name and social security number
Incarcerated - individual is incarcerated in a county, state, or federal facility or is on work release
Refusal of Work - individual was offered employment and refused or refused to work all hours offered by employer
Self Employed - individual started a business
Separation - the reason the individual is no longer working for their employer. The individual may have misrepresented the reason for separation from employment
Unreported Earnings - individual is working either on the books or under the table for cash while collecting unemployment compensation benefits
Other - must provide written details (may include not seeking employment)
Able and Available
Illness or Injury
Since what date?
Description
Hospitalization or rehabilitation facility
Since what date?
Name and/ or location
Address1
Address2
City
State
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Washington DC
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
--- OTHER ---
ZIP
Full-time caregiver for family member
Since what date?
Name of Family Member
Relationship to Claimant
Address1
Address2
City
State
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Washington DC
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
--- OTHER ---
ZIP
Full-time student
Since what date?
Name of School
Address1
Address2
City
State
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Washington DC
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
--- OTHER ---
ZIP
On vacation or out of the area
Since what date?
Location
Address1
Address2
City
State
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Washington DC
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
--- OTHER ---
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
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Washington DC
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
--- OTHER ---
ZIP
Date of Incarceration
Date of Release
Refusal of Work
Has this person refused an offer of full-time employment?
Yes
No
Name of business or individual offering employment
Telephone number of business or individual offering employment
Address1
Address2
City
State
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Washington DC
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
--- OTHER ---
ZIP
Has this person restricted their work hours at their present employment in order to continue to receive higher benefits?
Yes
No
When?
Name of current employer
Telephone number of current employer
Address1
Address2
City
State
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Washington DC
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
--- OTHER ---
ZIP
Self Employed
When?
Name of Business
Address1
Address2
City
State
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Washington DC
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
--- OTHER ---
ZIP
Telephone Number
Type of Business
How does the business advertise?
Do you have business customers' and/or suppliers' information?
Yes
No
Name of customers and/or suppliers
Telephone Number
Address1
Address2
City
State
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Washington DC
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
--- OTHER ---
ZIP
Separation
Did this individual voluntarily quit employment or was fired?
Voluntarily
Fired
When?
Name of Business
Address1
Address2
City
State
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Washington DC
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
--- OTHER ---
ZIP
Telephone Number
Unreported Earnings
Name of Employer
Telephone Number
Address1
Address2
City
State
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Washington DC
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
--- OTHER ---
ZIP
What type of work is the person doing?
Are they still working?
Yes
No
Unknown
Is this person working for a family member or friend?
Yes
No
Unknown
Relationship
When did they begin the work?
How are they being paid?
Cash
Check
Barter
Unknown
What days and hours do they work?
Where is their work location, if different than the employer's address?
Address1
Address2
City
State
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Washington DC
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
--- OTHER ---
ZIP
Other
Other
Additional Documentation
Do you have additional documentation that can be provided upon request?
Yes
No
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.