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Contractor Disclosure Form

This form allows contractors to comply with the reporting requirements in the Federal Acquisition Regulation amendment, 73 Fed. Reg. 67064, effective December 12, 2008. Specifically, contractors may use this form to satisfy the requirement that they notify, in writing, the Office of Inspector General, whenever the contractor has credible evidence that its principal, employee, agent, or subcontractor has committed a violation of the civil False Claims Act or a violation of Federal criminal law involving fraud, conflict of interest, bribery, or gratuities in connection with the award, performance, or closeout of a Department of Homeland Security (DHS) contract or any related subcontract. The individual completing this form must be an authorized representative empowered to speak for the company.

If you wish to provide information that does not fall within these guidelines, please visit the DHS Inspector General Hotline and submit a DHS OIG Investigative Referral Submission Form.

Instructions to complete form:

Fill in the appropriate information in the spaces provided. Appropriately mark any confidential or proprietary information.

Submit a Contractor Disclosure Report

After completing this form, please save the form, print it out and submit it by electronic facsimile to 202-254-4297 This e-mail address is being protected from spambots. You need JavaScript enabled to view it and also forward a copy of the Contractor Disclosure Report to the responsible Contracting Officer.  The OIG may contact you to obtain additional information or supporting materials.

Reports also may be submitted to:

U.S. Mail:
DHS Office of Inspector General
Attention: Office of Investigations Hotline
245 Murray Drive SW, Building 410/Mail Stop 2600
Washington, DC 20528