RepoRting SuSpected unemployment inSuRance FRaud and identity theFt The Georgia Department of Labor (GDOL) is committed to preserving the integrity of the Unemployment Trust Fund. Our department conducts many types of fraud and abuse investigations throughout the year on unemployment claims to ensure the accuracy of benefit payments made. Please provide as much information as possible. The more detailed information you can provide, the better it will help us with our investigations. Fields marked with an asterisk (*) are required. Section A: Your informAtion (optionAl) Prefer to remain anonymous? If you want to anonymously report suspicious or illegal activity, avoid leaving any personal information, such as your name and relationship to the individual you are reporting. Your Name: _______________________________________ Relationship to the individual ________________ (First, MI, Last) Your E-mail: _______________________________________ Phone number: _____ / _____ / ___________ Section B: SuSpect'S informAtion * Name: ____________________________________________ SSN: (if known): ________________________ (First, MI, Last) Street Address: ______________________________________ Phone number: _____ / _____ / ___________ City: _______________________________________________ State: __________ Zip: ____________________ DOB: _____ / _____ / ___________ * Fill in below the reason(s) you suspect the individual was involved in possible unemployment fraud and identity theft. Be specific. Additional information may be furnished. Please attach separate sheets of paper if needed, and include the individual's full name on each sheet. ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ _________________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ DOL-2915 (R-09/13) 1 American LegalNet, Inc. www.FormsWorkFlow.com RepoRting SuSpected unemployment inSuRance FRaud and identity theFt Section c: identifY theft informAtion Please complete this section if someone is using your social security number (SSN) or you are aware of someone using another individual's SSN to file a fraudulent UI claim and/or receiving UI benefits. You should also file a police report and notify the Federal Trade Commission either online at http://ftc.gov/idtheft or by phone at 1.877.438.4338. The following information should be provided to GDOL to assist in the investigation. If this section does not apply proceed to Section D. What is the SSN being used: ________-_______-_______ Is your SSN being used to file a fraudulent UI claim and/or receive UI benefits? YES _____ NO _____ Are you aware of someone using another individual's SSN to file a fraudulent UI claim and/or receive UI benefits? YES ______ NO _____ Is this individual using your name to file a fraudulent UI claim and/or receiving UI benefits? YES ______ NO _____ If no, what name is being used? ___________________________________________________________ Have you filed a report with your local police department? YES _____ NO _____ If yes, in which state was the report filed?___________-_____ Police Report Number: _______________ Is an investigation being conducted: YES _____ NO _____ Please provide a statement below regarding the incident that led to the identity being stolen: ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ _________________________________________________________________________________________________ Section d: emploYment informAtion If you suspect someone is working and using a fraudulent social security number (SSN), please complete this section. If this section does not apply, proceed to Section E. Is your SSN being fraudulently used for employment purposes? YES ______ NO _____ Are you aware of someone using another individual's SSN for employment purposes? YES ______ NO _____ Name and address of employer/business where the individual is working: Name: _____________________________________________________________________________________ (Business/Employer Name) Street Address: _______________________________________ Phone: ________-________-___ 2 DOL-2915 (R-09/13) American LegalNet, Inc. www.FormsWorkFlow.com RepoRting SuSpected unemployment inSuRance FRaud and identity theFt City:_____________________________________________ State:___________ Zip: _______________________ Name of contact person at this business____________________________________________________________ (First, MI, Last) What type of work is this individual performing?______________________________________________________ How is the individual paid? o Cash o Check o Barter o Other_______________________________________ When did the individual begin work? ______________________________________________________________ (MM/DD/YY) What days and hours does the individual work? ______________________________________________________ What name is the individual working under? ________________________________________________________ (First, MI, Last) Have you filed a report with your local police department? YES _____ NO _____ If yes, in which state was the report filed?_________________ Police Report Number: ______________ Is an investigation being conducted: YES _____ NO _____ Please provide a statement below regarding the incident that led to the identity being stolen: ___________________________________________________________________________________________ _______________