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Confidential Inquiry Form

* Indicates a required field.

* Your Name

Current Date

Physical Address

* Phone Number (Cell / Home)

* Your Email

How would you prefer to be contacted?
HomeCellEmail

Employer

Date Terminated

Reason for Termination

* Description of alleged fraud (be as detailed as possible):

When did the fraud begin?

Has the fraud stopped?
YesNo

Name of Products or Services involved in fraud:

Do you have any idea how much is involved in terms of dollar amounts that the government has paid out because of the fraud?
YesNo

Do you have any documents supporting your claims?
YesNo

If yes, please explain:

Have you reported or attempted to report this fraud to your employer or any third party?
YesNo

If yes, please explain:

Important note: if you are not comfortable completing this form or revealing your name, you can contact an attorney directly by calling 703-564-7318.

Please understand that by completing this agreement, the firm has not agreed to represent you nor have you agreed to retain us. Before agreeing to pursue your case, an evaluation and investigation will be necessary to make sure your case can be proven. Any information you provide for purposes of that evaluation will remain confidential. You should not post any information about the fraud on web sites or social media, and avoid blogging about the fraudulent practices. Take steps to secure any documentary evidence that could support your claim. As you consider pursing your case, please keep in mind that the time limit for bringing such claims can be as short as 6 years, so you should take steps early on have your case investigated. In addition, if someone else files a whistleblower case first against the same party or company for the same fraud, his claim make take priority over yours, limiting or in some cases precluding, your recovery.

I have read and understand the info above.

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