Your Name:

Address ( Steet, City,ST & Zip)

Home Phone:

Work Phone:

Other Phone:

When is the best time to contact you and how would you prefer we contact you?

Todays Date:

What states does the company do business in?

When did these deceitful act(s) begin? Are they still going on?

Have you filed any complaint about this situation or has anyone else filed a

complaint to your knowledge? If so, please explain:

How did you obtain knowledge of this deceitful activity?

Are there witnesses who would testify concerning this deceitful activity? If so,

would they be able to support your allegations?

What is the approximate dollar amount involved in the deceitful activity?

If we take this case, what result would you like to see accomplished?

Any other facts you would like us to know?

Do you have questions or concerns?

When and how did you hear about us?

Do you have documents or written proof of the deceitful activity?

If so, please describe the types of documents you have that will

prove the deceitful activities are occurring in order to obtain money

from the U.S. Government:

What company is committing this deceitful act(s)? (If you prefer, you

do not have to provide the company name at this time).

What is the nature of the deceitful act(s) used to improperly obtain

money from the U.S. Government or other non-compliance issue?

Please describe/explain.

False Claims Inquiry Form