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2. First Name*
3. Last Name*
4. Date of Birth*
6. Phone Number*
7. Email
9. Address*
10. City and State*
11. Zip code*
13. Have you received a debit card in the mail that you did not request?*

    1. Yes
    2. No
14. If yes, when did you receive the card?*
16. Were you notified of the unemployment claim by your employer?*

    1. Yes
    2. No
17. If yes, when were you notified?*
18. If yes, what is the name of your employer?*
20. Are you aware of any lost money due to this scam?*

    1. Yes
    2. No
21. If yes, how much has been lost?*
23. Please put any additional information in the box below.
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25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

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