Please fill out the following form
First Name:
Last Name:
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Telephone:
Email:
Was the fraud against
*
:
Medicare/Medicaid
Military Contractor
Private University
Pharmaceutical Fraud
Federal Government Fraud
Tax Fraud
Other
Note: Tax Fraud loss to the government must exceed 2 Million.
Your best estimate of the fraud amount
*
:
Less 500,000
Over 500,000
Over 2,000,000
Over 10,000,000
In detail let us know:
1) What activity is fraudulent
2) How did you find out the fraud was occurring
3) What proof you have of the fraud
4) Any other important information
Fill in information:
Verification:
All information is subject to attorney-client privilege & kept strictly confidential.