STATE OF MICHIGAN
GRETCHEN WHITMER DEPARTMENT OF LABOR AND ECONOMIC OPPORTUNITY JEFF DONOFRIO
GOVERNOR UNEMPLOYMENT INSURANCE AGENCY DIRECTOR
Authorized by
MCL 421.1 et seq.
•
UIA 6349
(Rev. 03-19)
UIA is an equal opportunity employer/program.
•
*063491903*
Statement of Identity Theft
Name: _______________________________ Claim #/Date: ___________________
SSN:
For Internal Use Only:
________________________ _____________________________ _______________
UIA Personnel Print Name Signature Date
________________________ ______________________
MiDAS Username Name of Local Oce
I did not le or attempt to reopen a claim for unemployment benets with the information
above.
I did not certify for unemployment benets on the claim listed above.
I did not receive any funds from the payment of unemployment benets on the claim listed
above.
I would like this claim led in my name to be withdrawn.
Contact Information: Address: ____________________________________________
____________________________________________
Telephone Number: ______________________________
Email Address: ______________________________
Certication: 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 benets, I may be required
to repay benets, 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) Oce. To nd the nearest
UIA Local Oce, 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.
