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Report someone receiving UI benefits at the same time they were incarcerated
Name of person receiving unemployment benefits:
Last 4 digits of their SSN:
Their address:
Their date of Birth (mm-dd-yyyy):
Their Telephone number:
xxx-xxx-xxxx
Name of the jail/prison in which they were/are incarcerated:
Date of their incarceration:
(mm-dd-yyyy)
Name of the person who is completing the vouchers for the person incarcerated:
Their relationship to the person incarcerated:
Provide a brief description of your concerns:
Please enter your contact information in case we need to contact you.
This is optional
and will be kept confidential.
Enter your name (
optional
):
Enter your phone number
xxx-xxx-xxxx (
optional
):
Enter your e-mail address (
optional
):
Enter your street address (
optional
):
Submit