Identity Theft Form

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Identity Theft Form

Please use this form to report the fraudulent use of an identity to collect Pennsylvania Unemployment Compensation benefits.

Contact Information
Please provide your contact information.
First Name	*		Last Name	*
Phone			Email

Theft Information (Victim Identification Information)
Please enter the victim identification information.
First Name			Middle Initial
Last Name			SSN
Address1			Address2
City			State
ZIP			Phone
Whose SSN is being used fraudulently to file or receive UC benefits? My SSNAnother individual’s SSN
Approximate date the identity theft began
Approximate date the identity theft was discovered
Did you give or allow access to your personal information, which includes your name, social security number, date of birth and PIN number?					YesNo
How did the other person get your social security number and Unemployment Compensation PIN?

What leads you to believe that identity theft has occurred?

Police Report Information
If your identity has been stolen, a police report may be required before the Department can proceed with processing this complaint.

Have you filed a report with your local police department?				YesNo
In what state was the report filed?
What is the name of the Police Department?
Police Report Number
Is an investigation being conducted?				YesNoI don't Know
Attach a copy of the police report (if available)

Suspect's Information (If known)
First Name			Middle Initial
Last Name			SSN
Date of Birth			Phone
Address1			Address2
City			State
ZIP			County
Reason why you suspect this person is involved in possible unemployment fraud and identity theft.

Penalty of Law Notice I certify that all Information I have provided in this document is correct and complete. I acknowledge that false statements in this document are punishable pursuant to 18 Pa. C.S. §4904, relating to unsworn falsification to authorities.
We will review the necessary files and records in light of the information you have provided to determine the most appropriate action. Thank you for assisting in our effort to fight fraud, waste and abuse.