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Department of Labor
Office of Inspector General
Contractor Disclosure Form

The Federal Acquisition Regulation (“FAR”) now requires all contractors to notify the government whenever they become aware of a contract overpayment or fraud.  If you are a federal contractor, or employee of same, and you have evidence of a violation of Federal law involving fraud, conflict of interest, bribery, gratuity violations, or violations of the False Claims Act, please complete and submit this form.

Section A: Official Submitting Disclosure

Your First Name:
Your Last Name:
Your Title:
Your Address (Line 1):
Your Address (Line 2):
Your City:
Your State:
Your Zip or Postal Code:
Your Telephone Number:
Your Email:

Section B: Contractor Information

Contractor Company Name:
Business Address (Line 1):
Business Address (Line 2):
Business City:
Business State / Province:
Business Zip or Postal Code:
Business Telephone Number:
Business Fax Number:

Section C: Disclosure Information

My company is the
I am reporting on the following contract:
   - Contract Number:
   - Title of Contract:
   - DOL Contracting Officer Name: First Name:
Last Name:
   - DOL Contracting Officer Address (Line 1):
   - DOL Contracting Officer Address (Line 2):
   - DOL Contracting Officer City:
   - DOL Contracting Officer State:
   - DOL Contracting Officer Zip or Postal Code:
   - DOL Component:
   - Contract Type
   - Contract Value: $
   - Description of services/supplies/system::
I am reporting on the following incident involving the above contract:
   - Estimated amount of loss: $
   - Loss description:
   - Incident date:
   - Date I learned of potential violation:
   - Has an investigation been conducted?
   - Please list any other entities you are notifying:
Additional Incident Attributes: does the incident you are reporting involve any of the following:
   - Duration of activity longer than 3 months?
   - Multiple individuals?
   - Actual or potential security compromise?
   - Actual or potential employee/public safety/health threat?
   - Actual or potential misuse of personally identifiable information?
   - Actual or potential national security threat?
Full Description:
   Please provide a complete description of the facts and circumstances surrounding the reported activities, including the evidence forming the basis of this report, the name of the individuals involved, dates, location, how the matter was discovered, potential witnesses and their involvement, and any corrective action taken by the company.

Section D: Certification and Confirmation

I certify under penalty of perjury that the information contained herein is true and correct to the best of my knowledge as of the date of this submission.
After clicking the “submit” box below, you will be provided with a “confirmation number” in reference to this disclosure submission


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