NASA Office of Inspector General

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Mandatory FAR Contractor Disclosure

CYBERHOTLINE | Contractor Disclosure Form

Instructions:

Fill in the form below. If your are unsure if this form applies or you have any questions, please contact Counsel to the Inspector General at HQ-OIG-Counsel@mail.nasa.gov

FAR Contractor Reporting Form

The purpose of this form is to allow the Contractor to notify, in writing, the agency Office of the Inspector General whenever the contractor has credible evidence that a principal, employee, agent, or subcontractor of the Contractor has committed a violation of the civil False Claims Act or a violation of Federal criminal law in connection with the award or performance of a contract or any related subcontract. The individual completing this form must be an officer or manager within the company for whom this report is being made and empowered to speak for the company by filing this report. If the information you wish to provide does not fall within these guidelines, please refer to the Inspector General Hotline/Fraud Reporting form.

Alternatively you may report by writing to the following address:
NASA Office of Inspector General
PO Box 23089
L’Enfant Plaza Station
Washington, DC 20026

Contact Info:
Your First Name:
Your Last Name:
Your Title:
Your Email:
Confirm Email:
Company Name:
Address 1:
Address 2:
City:
State/Province:
Zip/Postal Code:
Country:
Phone Number:
Fax Number:
Relationship: My Company is the: (Prime or Sub)
Prime Sub
I am reporting on: (Prime, Sub, Other)
Prime Sub Other
If other, please specify:
Contract Information:
Contract No:
Contract Officer Name:
Contract Officer Email:
Incident
Dollar Amount of Loss:
Loss Description:	Enter text here.
Incident Date:
Which of the following best describes the reason for reporting this matter (check all that apply):
Possible violation of civil False Claims Act Possible violation of Federal criminal law
Comments
Please provide a complete description of the facts and circumstances surrounding the reported incident, including names of individuals involved, dates, locations, how the matter was discovered, potential witnesses and their involvement, estimated monetary loss to the United States, and any corrective action taken by the company.
Enter text here.
Note:
Submission of willful false statement may violate 18 USC 1001.
NAME: Please type the numbers shown on the right:

NASA Office of Inspector General

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Mandatory FAR Contractor Disclosure

Contact Info:

Relationship:

Contract Information:

Incident

Comments

Note: