Fraud/Waste/Abuse Allegation Form

2. Which State government agency or entity is involved in your allegation?*
Other State government agency or entity:
3. Does your allegation involve an individual person or entity doing business with a State agency, such as a contractor or grant recipient?*
Yes
No
4. Name and position of the person(s) involved in the inappropriate activity:

5. When did the suspected loss or inappropriate activity occur?
6. Do you believe the suspected loss or inappropriate activity is still occurring?*
Yes
No
7. What is the suspected amount of loss, if any?
8. Use as much detail as possible to describe the activity that you believe was inappropriate (include what, where, why, and how):*
9. Please identify any specific law, rule, or other standard you think this activity violated:

10. When and how did this activity come to your attention?
11. Do you have any documentation or evidence to provide that supports your allegation?*
Yes
No
Documentation can be invoices, vouchers, receipts, payroll records, etc. Describe the specific items we should review and provide copies. Copies may be scanned and uploaded using the buttons below or mailed to the address at the end of this form.
File
File
File
File

12. Has your allegation been reported to any other individuals or entities, such as department management, a law enforcement agency, a lawyer, or others?*
Yes
No
If yes, please provide the name of the individual or entity, date filed, tracking number (if available), and status to date or outcome (if known).
13. Please provide identifying information for anyone else who may have witnessed or be aware of the incidents being described (name, e-mail address, phone number, etc.):
14. If there is any other information useful to our review of your allegation that has not already been submitted, please provide it below:

Optional Information About You:
First Name Last Name
Phone E-mail

Street Address Address Line 2 City State Zip Code

What is the best time frame for us to contact you if we need to?
Morning
Afternoon
Evening
Specific time frame:
What is the best method for us to contact you if we need to?
Phone
E-mail
Letter
Name
This field is for validation purposes and should be left unchanged.

Step 1 of 6

1. What type(s) of fraud, waste, or abuse are you reporting? (Check all that apply.)