Contractor Disclosure Form

This form allows contractors to comply with the reporting requirements in the Federal Acquisition Regulation amendment, 73 Fed. Reg. 67064, effective December 12, 2008. Specifically, contractors may use this form to satisfy the requirement that they notify, in writing, the Office of Inspector General, whenever the contractor has credible evidence that its principal, employee, agent, or subcontractor has committed a violation of the civil False Claims Act or a violation of Federal criminal law involving fraud, conflict of interest, bribery, or gratuities in connection with the award, performance, or closeout of a Department of Homeland Security (DHS) contract or any related subcontract. The individual completing this form must be an authorized representative empowered to speak for the company.

If you wish to provide information that does not fall within these guidelines, please visit the DHS Inspector General Hotline.

Instructions to complete form:

Fill in the appropriate information in the spaces provided. Appropriately mark any confidential or proprietary information.

After completing this form, please save the form, attach, and submit it by electronic mail addressed to DHSOIGHOTLINE@dhs.gov and forward a copy of the disclosure to the responsible Contracting Officer. The OIG may contact you to obtain additional information or supporting materials.

Reports also may be submitted to:

DHS Office of Inspector General
Attn: Hotline
245 Murray Drive, S.W. Building 410 – STOP 2600
Washington, DC 20528

Should you have any questions about this form or its applicability, please contact DHS OIG Washington Investigative Field Office at (703) 235-0840.

Make a Report