Contractor Disclosure Form | Office of Inspector General, Department of Housing and Urban Development

The Federal Acquisition Regulation (FAR) now requires all contractors to notify the government whenever they become aware of a contract overpayment or fraud. If you are a federal contractor, or employee of same, and you have evidence of a violation of Federal law involving fraud, conflict of interest, bribery, gratuity violations, or violations of the False Claims Act, please complete and submit this form.

How did you learn about the HUD OIG Hotline?

State

Presenter

Date

Other Description

SECTION A: Your Information

Your First Name:

Your Last Name:

Your Address 1:

Your Address 2:

Your City:

Your State:

Your Zip:

Your Phone:

Your Email:

Your Date of Birth:

Preferred Method of Contact

My company is the:

SECTION B: Who are you reporting

Contractor Company Name:

Business Address 1:

Business Address 2:

Business City:

Business State:

Business Zip:

Business Phone:

Business Fax:

WHEN DID THIS OCCUR?

Specific Date?

Date:

Date Range:

Add a witness?

WITNESS 1

Witness 1 - First Name:

Witness 1 - Last Name:

Witness 1 - Address 1:

Witness 1 - Address 2:

Witness 1 - City:

Witness 1 - State:

Witness 1 - Zip:

Witness 1 - Phone:

Add another witness?

WITNESS 2

Witness 2 - First Name:

Witness 2 - Last Name:

Witness 2 - Address 1:

Witness 2 - Address 2:

Witness 2 - City:

Witness 2 - State:

Witness 2 - Zip:

Witness 2 - Phone:

SECTION C: DISCLOSURE INFORMATION

Contract Number:

Title of Contract:

Contract Type:

Contract Value:

Description of services, supplies, or system:

I am reporting on the following incident involving the above contract:

Estimated amount of loss:

Loss description:

Date learned of potential violation:

Has an investigation been conducted?

Yes

Please list any other entities you are notifying:

Additional Incident Attributes: Does the incident you are reporting involve any of the following:

Duration of activity longer than 3 months?

Multiple individuals?

Actual or potential security compromise?

Actual or potential employee/public safety/health threat?

Actual or potential misuse of personally identifiable information?

Actual or potential national security threat?

Full Description:

Please provide a complete description of the facts and circumstances surrounding the reported activities, including the evidence forming the basis of this report, the name of the individuals involved, dates, location, how the matter was discovered, potential witnesses and their involvement, and any corrective action taken by the company.

SECTION D: CERTIFICATION AND CONFIRMATION

By clicking the "submit" button below, I certify under penalty of perjury that the information contained herein is true and correct to the best of my knowledge as of the date of this submission.

After clicking the “submit” button below, you will be provided with a “confirmation number” in reference to this disclosure submission.

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If you are submitting a report of fraud, waste, abuse, and/or mismanagement to OIG Hotline and have additional documentation to support the allegation please retain the information but annotate in the narrative that you have additional information. If it is determined that the additional information is needed, a HUD OIG employee will be in contact with you to facilitate the transfer of that information.