Federal and State Fraud Questionnaire

Last name

First name

Full address

Telephone number(s)

Email address

Retype email

Are the allegations that someone cheated the "Federal" Government?

Yes No

Are the allegations that someone cheated a "State" Government?

Yes No

Briefly explain the fraud allegations, but without mentioning the names of either the person or company that committed the fraud

Why do you believe it was fraudulent instead of either an innocent mistake by the company or a poor buying decision by the Government?

Do not mention any names

How much money would you estimate the government has paid out based upon the false statements or otherwise has been financially harmed by the fraud?

In your response, describe how you calculated or estimated the amount

How did you become aware of the fraud?

Do not mention names

Do you have any documents to help prove the fraud?

If so, briefly state the type of documents

When did the fraud occur?

Please state which years, when it stopped and if it still going on

Did you once work for the company committing the fraud?

Yes No

Do you now work for the company committing the fraud?

Yes No

Did you make any complaints about the fraud to the person or company that committed the fraud?

If yes, without mentioning any names, briefly state what you did and how they responded

At the time of the fraud, did anyone at the government know of the acts which you think were false or fraudulent?

If yes, without mentioning any names, briefly state what they knew and how they knew it

Have your allegations been the subject of any legal action or newspaper story, or have the allegations been disclosed in any lawsuit, agency hearing, congressional hearing, or government audit?

If so, briefly describe them without mentioning any names

Have you talked to another attorney about this matter?

Yes No

Have you filed a lawsuit against anyone or a company before?

If yes, briefly describe them without mentioning names

* I have read and agree to your statements

Statements: Although we will treat the information confidential, the transmission of any information is not intended to create, and receipt does not constitute, an attorney client relationship. Even if you submit the questionnaire to me, that does not make me your lawyer. Instead, we will use your information to investigate the matter and to determine whether we can and will represent you in bringing your whistleblower case. Only once we both sign a written agreement will we actually become your lawyer and advocate. A fraud case can take a number of years from start to finish and it can be expensive for a lawyer to take a case. Therefore, we conduct a thorough analysis of cases and we do not accept every case. It may take time to evaluate your questionnaire, and we may be busy on other matters at the time you send your questionnaire. If our time constraints do not fit your needs, you may wish to discuss your matter with another attorney.

Rewards for Reporting Fraud

Federal and State Fraud Questionnaire