A.  OFFICIAL SUBMITTING DISCLOSURE

A.4.  Title/Position:

A.5.  Email: 
        Re-Enter Email:

B.  CONTRACTOR DATA

B.1.  Contractor:

B.2.  Affected Corporate Branch/Division/Sector:

B.3.  Doing Business As (dba):

B.5.  Telephone Number:
ex. (123)1234567 ext.89

B.6.  Commercial and Government Entity Code (CAGE):

B.7.  Data Universal Numbering System (DUNS):

B.8.  Senior Corporate Point of Contact (POC):   

B.8.1 Senior Corporate (POC) Telephone Number:
ex. (123)1234567 ext.89

C.  AFFECTED CONTRACT 1

C.1.  Number:

C.2.  Short Title:

C.3.  Contract Type:

C.4.  Contract Value:

C.5.  Description of Services/Supplies/System: 

C.6.  Identify End Users:

C.7.  Contracting Officer Name:

C.8.  Contracting Office Address:

C.8.1. Contracting Officer’s Telephone Number:
ex. (123)1234567 ext.89

C.9.  Contract performance location:

C.10. Contracting Officer’s Technical Representative (COTR):

C.11.  COTR Telephone Number:
ex. (123)1234567 ext.89

C.12. List all Federal agencies currently doing business with i.e., Veteran’s Administration, General Service Administration:

D.  DISCLOSURE

D.1.  Date Contractor learned of potential violation:

D.2. Provide a full description of the nature of the violation(s) being disclosed, including the period during which the violation occurred, names of individuals involved and an explanation of their roles in the allegations and the relevant periods of their involvement:

D.3.  Safety or operational hazards:

D.3.1. Measures taken to mitigate safety or operational hazards:

D.4.  Estimated financial impact to the Government:

E. OVERPAYMENT

E.1  Did an overpayment occur:

E.2.  Estimated amount of overpayment:

F.  COMPANY INTERNAL INVESTIGATION

F.1. Has an investigation been conducted: 

F.2.  Describe the scope of the investigation (records reviewed, number and positions of employees interviewed, etc.):

F.3. Is the company willing to provide a copy of the investigative report:

F.4. Measures taken to prevent recurrence:

G.  ACKNOWLEDGEMENTS

G.1. I state that this Contractor Disclosure Program submission is true and accurate to the best of my knowledge as of the date of its submission.

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G.2. I understand and acknowledge that the submission of the foregoing Contractor Disclosure does not bar, prohibit, foreclose or preclude the Government from pursuing any and all criminal, civil and/or administrative remedies provided to it by law and/or regulation against (a) the business entity(ies) making the forgoing Contractor Disclosure Program submission, (b) any other business entities mentioned in the submission and/or (c) any individuals mentioned in the submission.

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