Complete the form below. If you are unsure if this form applies or you have any questions, please call the OIG hotline at 800-409-9926. Alternatively you may report by writing to the following address: Office of Inspector General Hotline PO Box 9778 Arlington, VA 22219 The purpose of this form is to allow the Contractor to notify, in writing, the agency Office of the Inspector General whenever the contractor has credible evidence that a principal, employee, agent, or subcontractor of the Contractor has committed a violation of the civil False Claims Act or a violation of Federal criminal law in connection with the award or performance of a contract or any related subcontract. The individual completing this form must be an officer or manager within the company for whom this report is being made and empowered to speak for the company by filing this report. If the information you wish to provide does not fall within these guidelines, please refer to the Inspector General Hotline/Fraud Reporting form. Note: Fields marked by * are required Your Information Your First Name * Your Last Name * Your Title Your E-mail Confirm E-mail Your Company's Name * Address 1 Address 2 City State/Province Zip/Postal Code: Country Phone Number * Fax Number Relationship My Company is the (Prime, Sub) Prime Sub I am reporting on (Prime, Sub, Other) Prime Sub Other (please specify)... I am reporting on (Prime, Sub, Other) Other (please specify)... Name of the company you are reporting on Contract Information (if known) Contract No Contract Officer Name Contract Officer E-mail Incident Dollar Amount of Loss Loss Description * Incident Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022 Which of the following best describes the reason for reporting this matter? (check all that apply) Possible violation of civil False Claims Act Possible violation of Federal criminal law Additional Information Comments Please provide a complete description of the facts and circumstances surrounding the reported incident, including names of individuals involved, dates, locations, how the matter was discovered, potential witnesses and their involvement, estimated monetary loss to the United States, and any corrective action taken by the company. By submitting this form, you certify that all of the statements made in this allegation (including continuation pages and addenda) are true, complete, and correct to the best of your knowledge and you understand that a deliberate false statement, or deliberate concealment of a material fact relating to the allegations herein is a criminal offense (Title 18 U.S.C. Section 1001) for which you may be prosecuted. Leave this field blank Submit
