Contractor Reporting Form - Contractor Disclosure

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Contractor Reporting Form

Contractors may notify the OIG of evidence that a principal, employee, agent, or subcontractor has violated the civil False Claims Act or Federal criminal law (fraud, conflict of interest, bribery, or gratuity violations) concerning the award, performance, or closeout 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. Submission of this electronic form automatically generates a confirmation email. Receipt of this email confirms that the OIG received the information provided.

If the information you wish to provide does not fall within these guidelines, please call the DOI Inspector General Hotline.

Fields marked with * are required.

Your First Name *

Your Last Name *

Your Title *

Your Company E-Mail *

Company Address *

Company Address 2

Company City*

Company State*

Company Zip*

Company Country*

Company Phone Number:*

Company Fax Number:

My company is the Prime Contractor:*

My company is a Sub Contractor:*

I am reporting on my Company:*

Name of Company I am Reporting On:*

Affected Bureau within DOI:*

If other:

DUNS or TINS:

EIN (if known):

Contract Number (if known):

Contracting Officer Name:

Contracting Officer Email:

Dollar Amount of Loss:

Loss Description *

Was there an Overpayment?*

Incident Date (DD/MM/YYYY):*
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Estimated Amount of Overpayment:

Was a Company Investigation Initiated?*

Date Company Investigation Started (DD/MM/YYYY):*
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Name of Company Investigator:

Was a Company Investigation Completed?*

Is Company willing to provide copy of report?*

Measures taken to prevent recurrence: *

Duration of Activity longer than 3 months:*

Property Loss greater than $ 5000.00:*

Monetary Loss greater than $ 5000.00:*

Multiple Individuals involved (list names):

Actual/Potential Security Compromise:*

Actual/Potential Public Safety threat:*

Actual/Potential Misuse of Personal Information:*

Counsel concurred with this reporting:*

Comments: Please provide a complete description of the facts and circumstances surrounding the reported incident, including the evidence forming the basis of this report, the names of the individuals involved, dates, location, how the matter was discovered, potential witnesses and their involvement and any corrective action taken by the company. (maximum 1000 characters)

Your comments: *

Please list any other entities you are notifying:

"I declare (certify/verify/state) under penalty of perjury (28 U.S.C. 1746) that this Contractor Disclosure Program submission is true and accurate to the best of my knowledge as of the date of its submission." (Must select Yes to submit).*

"I understand and acknowledge that the submission of the foregoing Contractor Disclosure Program submission 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 indivuduals mentioned in the submission." (Must select Yes to submit).*

Certification: I certify that the information contained herein is true and correct to the best of my knowledge(Enter your name):*

Recovery Oversight

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