First Name:      Last Name:  

Email:     Phone Number:

B. Claimant Information
Fields marked with an asterisk (*) are required.

Information about the person suspected of committing fraud:

*Full Name:    

Social Security Number (if known)

Address 

City   State    Zip 

Phone Number:

*Reason(s) you suspect they were involved in possible unemployment fraud. Be specific:

Name of business or employer where this person is working:

Employer Address: 

City   State    Zip 

How were they paid?  Cash  Check  Barter    Other

If other, please explain:

When did the person begin work? (MM/DD/YYYY) 

What days and hours does this person work? 

What type of work were they doing? 

For reporting purposes, how did you hear about our fraud hotline?

 Billboard Website Word of Mouth Other:

If this person was unable to work due to being in jail, on vacation, ill or injured, please give as much information as possible:

• Name of the business
• Address
• Phone number
• Advertising information
• Name of customer(s) who used this business and their address(es) and phone number(s)
• Any other information proving the business exists

Other information or comments: (such as physical description, social networking site, i.e., Facebook, type of car driven, etc.

To report possible fraud by an employer please provide, business name, address, phone number, owners name, nature of the fraudulent activity, such as:

• Business not registered with the state.
• Not reporting employees or wages to the state.
• Paying employees under the table.
• Other information that may be helpful to an investigation.
   

C. How to submit information

You can print this form and fax or mail it to us. Be sure all information is visible before printing. Do not mail or fax this form if you clicked "Submit".

Connecticut Department of Labor

Benefit Payment Control Unit

200 Folly Brook Blvd.

Wethersfield, CT 06109

Fax (860) 263-6343