Contractor and Grantee Self Report Form

Indicates required field

Contractors and grantees must, in a timely manner, disclose certain criminal acts and civil violations, in writing, to the OIG. Completion of this form meets these obligations.

Contractors: 48 CFR 52.203-13(b)(3) states that the Contractor shall timely disclose, in writing, to the agency Office of the Inspector General (OIG), with a copy to the Contracting Officer, whenever, in connection with the award, performance, or closeout of this contract or any subcontract there-under, the Contractor has credible evidence that a principal, employee, agent, or subcontractor of the Contractor has committed:

A violation of Federal criminal law involving fraud, conflict of interest, bribery, or gratuity violations found in Title 18 of the United States Code; or
A violation of the civil False Claims Act (31 U.S.C. §§ 3729 - 3733).

Grantees: 2 CFR 200.113 states that the non-Federal entity or applicant for a Federal award must disclose, in a timely manner, in writing to the Federal awarding agency or pass-through entity all violations of Federal criminal law involving fraud, bribery, or gratuity violations potentially affecting the Federal award. Non-Federal entities that have received a Federal award including the term and condition outlined in Appendix XII - Award Term and Condition for Recipient Integrity and Performance Matters are required to report certain civil, criminal, or administrative proceedings to SAM. Failure to make required disclosures can result in any of the remedies described in § 200.338, including suspension or debarment.

If you are not a contractor or grantee, or if you want to report something that is not described above, please use the OIG Hotline Submission Form [MM1] to notify OIG.

WARNING - Do not include any classified information. If reporting your complaint requires the disclosure of classified information DO NOT USE THIS FORM. Instead, please contact the OIG Hotline at: 202-647-3320 or 800-409-9926 for proper reporting procedures. Do NOT discuss classified information over the phone.

Fields with a red asterisk (*) are mandatory.

Your Contact Information

Your Name

Your Title

Your E-mail Address

Confirm E-mail

Your Employer/Company Name

Your Employer/Company Address

Street 2

City/Town

State/Province

ZIP/Postal Code

Country

Your Phone (Mobile)

Your Phone (Work)

Your Phone (Home)

Contractor/Grantee Information

Contractor/Grantee Name

Please add as many names as are relevant, one per line.

Contractor/Grantee Phone

Contractor/Grantee Address

Street 2

City/Town

State/Province

ZIP/Postal Code

Country

Contract/Grant Information

Contract/Grant Name

Contract/Grant Number

Contracting/Grants Officer's Name

Contracting/Grants Officer's E-mail

Contracting/Grants Officer's Phone

Contract/Grant Issuing Office/Bureau/Embassy/Consulate

Incident Details

Name of individual or company responsible

Where did this incident occur (office/post/city/state/country)?

When did this incident occur?

How do you know about this incident?

Please summarize what you know about this incident

Do you have any further evidence of this incident such as documents, photos, e-mails, etc.?

Yes

Certification

By submitting this form, I certify that all of the statements made in this allegation (including continuation pages and addenda) are true, and correct to the best of my knowledge and understand that a deliberate false statement, or deliberate concealment of a material fact relating to the allegation herein is a criminal offfense (Title 18 U.S.C. § 1001) for which I may be prosecuted.