Unemployment Insurance Fraud Reporting Form (anonymous tip) Please enter the following information about your tip: Claimant Information Claimant Name * Address Line1 Address Line2 City State AA-Armed Forces (Americas) AE-Armed Forces (Europe) AP-Armed Forces (Pacific) AL-Alabama AK-Alaska AZ-Arizona AR-Arkansas AS-American Samoa CA-California CO-Colorado CT-Connecticut DC-District of Columbia DE-Delaware FL-Florida FM-Federated lsts of Micronesia GA-Georgia GU-Guam HI-Hawaii ID-Idaho IL-Illinois IN-Indiana IA-Iowa KS-Kansas KY-Kentucky LA-Louisiana ME-Maine MH-Marshall Islands MD-Maryland MA-Massachusetts MI-Michigan MN-Minnesota MS-Mississippi MO-Missouri MP-Northern Mariana Islands MT-Montana NE-Nebraska NV-Nevada NH-New Hampshire NJ-New Jersey NM-New Mexico NY-New York NC-North Carolina ND-North Dakota OH-Ohio OK-Oklahoma OR-Oregon PA-Pennsylvania PR-Puerto Rico PW-Palau RI-Rhode Island SC-South Carolina SD-South Dakota TN-Tennessee TX-Texas UT-Utah VT-Vermont VA-Virginia VI-Virgin Islands WA-Washington WV-West Virginia WI-Wisconsin WY-Wyoming Zip Last 4# SSN (last 4 digits of claimant's Social Security Number) Fraudulent Client Information Client Working? Yes No To receive UI benefits, a person must be able and available to work. If the claimant is unable to work, please indicate the reason below. Client unable to Work? Yes No Any other information you feel is important for us to know to complete our investigation: (max. 4000 chars) Information Submitted by If you would like to be contacted for additional information by an investigator, please give your name and number below. You will remain anonymous. All information given is confidential. Full Name Phone # OR you may call (502) 564-2387 to report fraud.