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FAR Contractor Reporting Form

Complete the form below. If you are unsure if this form applies or you have any questions, please contact the OIG hotline at oighotline@state.gov or call 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 Company's








Relationship


Prime
Sub


Prime
Sub
Other

Name of the company

Contract Information (if known):



Incident:



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

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.

Note:
Submission of willful false statement may violate 18 USC 1001.