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6349e 3-19-18 617923 7 PDF

This document is a statement of identity theft form from the State of Michigan Unemployment Insurance Agency. It allows an individual to claim that they did not file or receive unemployment benefits for a specific claim filed in their name. The form collects contact information and a signature certifying the information is true before it can be submitted to the agency to dispute an identity theft unemployment claim.

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Tone Mrlaw
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92 views1 page

6349e 3-19-18 617923 7 PDF

This document is a statement of identity theft form from the State of Michigan Unemployment Insurance Agency. It allows an individual to claim that they did not file or receive unemployment benefits for a specific claim filed in their name. The form collects contact information and a signature certifying the information is true before it can be submitted to the agency to dispute an identity theft unemployment claim.

Uploaded by

Tone Mrlaw
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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UIA 6349

(Rev. 03-19)

GRETCHEN WHITMER
GOVERNOR
STATE OF MICHIGAN
DEPARTMENT OF LABOR AND ECONOMIC OPPORTUNITY
UNEMPLOYMENT INSURANCE AGENCY
RESET FORM
Authorized by
MCL 421.1 et seq.

JEFF DONOFRIO
DIRECTOR
•
Statement of Identity Theft
Name: _______________________________ Claim #/Date: ___________________
SSN:

I did not file or attempt to reopen a claim for unemployment benefits with the information
above.

I did not certify for unemployment benefits on the claim listed above.

I did not receive any funds from the payment of unemployment benefits on the claim listed
above.

I would like this claim filed in my name to be withdrawn.

Contact Information: Address: ____________________________________________


____________________________________________
Telephone Number: ______________________________
Email Address: ______________________________

Certification: I certify that the information I have reported is true and correct. I understand that if I intentionally
make a false statement, misrepresent facts or conceal material information to obtain benefits, I may be required
to repay benefits, charged penalties and could be subject to criminal prosecution.

_____________________________ _________________ ___________________


Signature Date Telephone Number

____________________________________
Print Name

You can return this form in person at your local Unemployment Insurance Agency (UIA) Office. To find the nearest
UIA Local Office, go to www.michigan.gov/uia under UIA Quick Links. You can also return this form by mail to the
Unemployment Insurance Agency, P.O. Box 169, Grand Rapids, MI 49501-0169 or fax to 1-517-636-0427.

For Internal Use Only:


________________________ _____________________________ _______________
UIA Personnel Print Name Signature Date

________________________ ______________________
MiDAS Username Name of Local Office

•
*063491903* UIA is an equal opportunity employer/program.

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