This form is to report reemployment assistance fraud only. You may also report fraud through the reemployment assistance fraud hotline 1-800-342-9909.

Please provide the following information.

(Last four digits of claimant's Social Security number)
(Name of business where claimant works)
(Business number where claimant works)
(Job site address)
An equal opportunity employer/program.  Auxiliary aids and services are available upon request to individuals with disabilities.
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