OIG Complaint Form

Please provide all available information about the person(s) who you believe committed the potential fraud, waste or abuse. If the information is unknown, leave the field blank. However, without a known subject our ability to investigate this allegation will be somewhat limited. Please provide all information you have about the subject

1. Is the subject a: *

a. Subject- Legal Name

b. Name of business (if applicable)

c. Other Names/Aliases Used by Subject- Full Name

d. Subject- Address (include city, state, and zip code)

e. Subject Work Phone

f. Subject Home Phone

g. Subject Cell Phone

2. Another person or business involved? *

YES

a. Subject II- Legal Name

b. Name of business II (if applicable)

c. Other Names/Aliases Used by Subject II- Full Name

d. Subject II- Address (include city, state, and zip code)

e. Subject II- Work Phone

f. Subject II- Home Phone

g. Subject II- Cell Phone

3. What one category best describes the violation you believe occurred? *

Category- Other (Explain)

4. Provide an explanation of the issue you believe to be the violation. *

Keep in mind the more specific details you provide the better able we will be to respond to your complaint. Remember to tell us WHO you believe committed a violation, WHAT they did, WHERE the violation occurred, WHEN the violation occurred, HOW it happened and if you know WHY the person committed the violation.

5. May we refer your complaint to the appropriate agency? (If applicable) *

YES

The information you provided us is important and, in some cases, should be referred to another agency for action. When we refer a complaint, we monitor that agency's action and follow up on the complaint.

6. If we refer a complaint to another agency may we include your contact information? *

YES

Office of the Inspector General

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OIG Complaint Form

-COMPLAINT FORM-