Date

Full Name

Street Address

City

State

Zip Code

Phone

Fax

Email

List two large cities located near your address:

What is your preferred method of contact?
Phone
Fax
Email

What do you want to report? (Use the space below)
Summary:

Name & address of employer where you experienced discrimination, reported or discovered fraud/misconduct
and/or the employer for which you would like to make an initial fraud report:

Are you currently employed?
Yes
No

Position/Title

If you have previously reported fraud or misconduct, when and to whom did you make this report? (Give specific dates)

If applicable, when and what type of retaliation have you been subjected?
(Give specific dates; details can be in your summary)

Are you reporting fraud committed at the expense of a governmental entity?
Yes
No

If so:

Name & Address of the Corporation, person or entity who made the false claim


What Agency has been defrauded?


Has there been a public disclosure of your case in any media?
Yes
No


If yes please describe where the disclosure occurred and when:

Are you reporting tax fraud against the IRS?
Yes
No

If so:

Name & Address of the Corporation, person or entity who responsible for the tax fraud:


Approximately how much money is involved in the fraud?


Has there been a public disclosure of your case in any media?
Yes
No


If yes please describe where the disclosure occurred and when:

Do you currently have an attorney?
Yes
No

If so please tell us the name and address of your Attorney:

Do you have a case pending before a court or agency?
Yes
No

If yes, give name of case and current status:

Would you like an Attorney Referral?
An Attorney Referral does not necessarily result in attorney representation.
Yes
No

Can the NWLDEF send a copy of this form to the referred attorney?
Yes
No

Can the NWLDEF discuss your case with members of the media?
Yes
No

Can the NWLDEF provide your email address to the National Whistleblower Center's Action Alert network
in order to provide you with bulletins and updates on matters related to whistleblowing?
Yes
No

How did you find out about the Attorney referral Service?
(Optional)

Thank You for Completing This Form. This form may be returned to the NWLDEF via e-mail,
regular mail/federal express or by Fax to the following address: