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Whistleblower help

This form is intended to be used only to evaluate your claim and/or make a referral to legal counsel. It is not a commitment to provide legal representation. Regardless of our evaluation of your situation, the contents of the form shall remain confidential.

Your information

First name*

Address*

State*

Phone*

Email*

What is your preferred method of contact?*
PhoneFaxEmail

Last name*

City*

Zip*

Fax

Name two large cities near you*

Questions

What do you want to report?
Name & address of employer where you experienced discrimination, reported or discovered fraud/misconduct and/or the employer for which you would like to make an initial fraud report.
Are you currently employed?*
YesNo
Position title
If you have previously reported fraud or misconduct, when and to whom did you make this report? Provide specific dates.
If applicable, when and what type of retaliation have you been subjected? Provide specific dates; details can be in your summary.*
Are you reporting fraud committed at the expense of a governmental entity?
YesNo
If so, name & address of the corporation, person or entity who made the false claim.
What agency has been defrauded?
Has there been a public disclosure of your case in any media?
YesNo
If yes, please describe where the disclosure occurred and when. Provide specific dates; details can be in your summary.
Are you reporting tax fraud against the IRS?
YesNo
If so, what is the name & address of the corporation, person, or entity responsible for the tax fraud?
Approximately how much money is involved in the fraud?
Has there been a public disclosure of your case in any media?
YesNo
If yes, please describe where the disclosure occurred and when. Provide specific dates; details can be in your summary
Do you currently have an attorney?*
YesNo
If so, please tell us the name and address of your attorney.
Do you have a case pending before a court or an agency?*
YesNo
If yes, give the name of your case and current status.