Unemployment Online Assistance Center - Report Unauthorized Change

Unemployment Online Assistance Center - Report Unauthorized Change
Necesita ver este formulario en español?
Haga clic en este enlace para acceder a la versión en español.
EXTREMELY IMPORTANT NOTE REGARDING THE ENTRY OF CONFIDENTIAL INFORMATION:

The form below requires confidential information. Therefore, it is vital for you to close your browser completely after submitting this form. This will prevent others from accessing the information you have entered. To close your browser, click the "x" in the top right-hand corner of the browser window.

IMPORTANT NOTE: Verify you completed the form and all information is accurate and matches your filed claim before you submit it.
You have accessed this page because you received a notice stating that you accessed or changed your ReEmployCT unemployment benefits payment method, mailing address, email address, or password and you are certifying that you did not authorize this change.

For Users Using Screen readers:
Red asterisk (*) = required field
I certify that I am the claimant indicated below. I understand that the law provides penalties for making false statements or any misrepresentation to obtain unemployment benefits.*

I AGREE
Social Security Number *
(Format = ######### - no dashes please)
Full Name*

First NameLast Name
Mother's Maiden Name (for verification purposes):*
Date of Birth (for verification purposes): *

MonthDayYear
Date
Email Address: (to contact you only for confirmation)
example@example.com
Contact Phone:
Please enter a valid phone number.
Based on the notice I received, I am reporting that (select any that apply):*

I did not change my ReEmployCT unemployment benefits payment method.I did not change my mailing address on my ReEmployCT unemployment benefits account.I did not change the password on my ReEmployCT unemployment benefits account.I did not change my email address on my ReEmployCT.I did not create a ReEmployCT unemployment benefits account.
Please verify that you are human*
Draw image below for verification:*
Should be Empty: