PLEASE PROVIDE THE FOLLOWING INFORMATION.
(“*” mandatory information)
CONTRACTOR INFORMATION
First Name
*
Last Name
*
Business Title
*
Business Email
*
Confirm Business Email
*
COMPANY INFORMATION
Company Name
*
Business Address 1
*
Business Address 2
*
City
*
State/Province
*
- Choose One -
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip/Postal Code
*
HUD CONTRACT INFORMATION
Contract Number
*
DUNS or TINS
Contracting Officer's Name
Contracting Officer's Phone Number
Description of Services/Supplies/System delivered under this contract
*
VIOLATION INFORMATION
Did overpayment occur
*
Yes
No
If yes, what was the estimated amount of loss to the government
Loss Description
*
Incident Date
*
Date contractor learned of potential violation
*
Has an investigation been conducted?
*
Yes
No
Does the incident you are reporting include any of the following attributes.
Check all that apply
Duration of the activity longer than
3 months
Multiple individuals involved
Actual overpayment
Potential overpayment
Actual false claim
Potential false claim
Actual conflict of interest
Potential conflict of interest
Actual bribery or gratuity
Potential bribery or gratuity
Actual security compromise
Potential security compromise
Actual employee/public safety/
health threat
Potential employee/public safety/
health threat
Actual misuse of personally
identifiable information
Potential misuse of personally
identifiable information
Actual national security threat
Potential national security threat
Other (Describe below)
Please provide a complete description of the facts and circumstances surrounding the reported activities, 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
*
Please list any other entities you are notifying
CERTIFICATIONS
“I certify that the information contained herein is true and correct to the best of my knowledge.”
*
Agree
"I understand and acknowledge that the submission of the foregoing information 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 the business entity(ies) identified in the submission and/or any individuals identified in the submission.”
*
Agree
Security Code (please type the code you see in the box)
*
