Statement of Identity Theft
Uploaded by
Clickon DetroitStatement of Identity Theft
Uploaded by
Clickon DetroitUIA 6349
(Rev. 02-18)
RICK SNYDER
STATE OF MICHIGAN
DEPARTMENT OF TALENT AND ECONOMIC DEVELOPMENT
Authorized by
MCL 421.1 et seq.
ROGER CURTIS
•
GOVERNOR TALENT INVESTMENT AGENCY DIRECTOR
UNEMPLOYMENT INSURANCE WANDA M. STOKES
DIRECTOR
Statement of Identity Theft
Name: ____________________________________ Case #/Letter ID: ___________________
Last Four Digits of 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I would like this claim filed in my name to be withdrawn.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
____________________________________________________
Print Name
You can return this form in person at your local Problem Resolution Office (PRO). To find the nearest PRO, go to www.
michigan.gov/uia under UIA Quick Links. You can also return this form by mail to Unemployment Insurance, P.O. Box
169, Grand Rapids, MI 49501-0169 or fax to 1-517-636-0427.
For Internal Use Only:
________________________ ________________________________ _______________
UI Personnel Print Name Signature Date
________________________ ______________________
MiDAS Username Name of PRO
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*063491802* TED is an equal opportunity employer/program.