Professional WomanMale Nurse


business manWoman construction worker
 

Department of Employment, Training and Rehabilitation
 

DETR Unemployment Insurance Fraud Reporting Form

Please provide all known information regarding the person you suspect of committing fraud.  Fields marked with an asterisk (*) are required.  Your identity will be kept confidential.  We cannot provide information on the results of any investigation.  Your information is appreciated.

What leads you to believe this person is committing fraud? (max 300 characters)
Suspected person's:
First Name * 
Middle Initial
Last Name *
Also known as (AKA):
Social Security Number
Physical Street Address
Apt/Space No
City
State
Zip
Mailing Street Address or PO Box
(if different from Physical Address)
Mail Apt/Space No
Mail City
Mail State
Mail Zip
Telephone Number
Email Address
Date of Birth   OR (mm/dd/yyyy)
Approximate Age
Where is this person working?
Employer Name *
Employer Street Address
Employer City
Employer State
Employer Zip
Employer Phone
Employer Website
 Additional Work Information
When did this person begin working (Date) (mm/dd/yyyy)
How did you learn about this? (max 300 characters):
How is this person paid?
Please add any additional information you would like to provide. (max 300 characters):
May we contact you?  (All information is kept strictly confidential).
First Name
Last Name
Telephone Number
Email Address
Security Verification
Security Image CAPTCHA Image Reload Image
Please enter the code in the image above.   Use browser Back button to return to completed form
By submitting this report, I certify that all information provided is true to the best of my knowledge.  I understand that filing a false report is a fraudulent act and may be subject to civil and criminal action.


Nevada Department of Employment, Training & Rehabilitation
500 East Third Street
Carson City, NV 89713

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