Reporting Suspected Unemployment Insurance Fraud and Abuse The Georgia Department of Labor 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 provide, the better it will help us with our investigation. 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. However, it is helpful to the investigation if you can be reached for additional questions, if needed. Your Name: ________________________________ (First, MI, Last) Relationship to the individual: ____________________ Your Phone number: _______-________-___________ Your E-mail: ________________________________ Section B: Suspect's Information * Name: ___________________________________________ (First, MI, Last) SSN: (if known): ________-_______-_______ Phone:______-______-_____________ Zip: ___________________ Street Address: ___________________________________________ City:__________________________________________ DOB: ______/______/______ State:____________ * Fill in below the reason(s) you suspect the individual was involved in possible unemployment fraud and abuse. Be specific. Additional information may be furnished. Please attach separate sheets of paper. Include the individual's full name on each sheet. ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ __________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Section C: Employment Information 1 DOL-2914 (R-2/15) American LegalNet, Inc. www.FormsWorkFlow.com Reporting Suspected Unemployment Insurance Fraud and Abuse Section C: Employment Information If you suspect the individual is receiving UI benefits but he/she is not reporting working and earning money, to include being paid cash "under the table", please complete this section. If this section does not apply, proceed to Section D. Name and address of employer/business where this person is working: Name: _____________________________________________________________________________________ (Business/Employer Name) Street Address: _________________________________________ Phone:_______-_______-_____________ City:_____________________________________________ State: ____________ Zip: _______________ What type of work is this person doing?_________________________________________________________ How is the individual paid? q Cash q Check q Barter q Other______________________________ (please check all that apply) When did the person begin work? _____________________________________________________________ (MM/DD/YY) What days and hours does this person work? ____________________________________________________ Section D: Other Information If you suspect the individual is receiving UI benefits but is not looking for work, falsifying their work search efforts, or unable or unavailable to seek or accept work due to being in jail, illness/injury, out of town, on vacation, or self employed, please complete this section. If this section does not apply, proceed to Section E. Please read each report description below to make sure you are responding accurately. If this individual was unable and unavailable to work due to being in jail, illness/injury, out of town, or on vacation etc., please provide as much information as possible (e.g., reason the person is unable and unavailable to work, beginning and ending dates the individual was unable and unavailable, etc). ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ________________________________________________________________________________________________ DOL-2914 (R-2/15) 2 American LegalNet, Inc. www.FormsWorkFlow.com Reporting Suspected Unemployment Insurance Fraud and Abuse If this individual is not looking for work or has falsified their work search efforts, please provide as much information as possible (e.g., a description of their fraudulent activity and the period of time the activity took place etc). ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ________________________________________________________________________________________________ ___________________________________________________________________________________________ If the individual started a business, please give the name, address, and phone number of the business, type of business, advertising information, days and hours the person works, and any other information that may be used to prove the business exists: ___________________________________________________________________________________________