Department of Defense > Forms > Contractor Disclosure

Full Name

First

Middle

Last

Suffix

Address

Street

City

State

Country

Zip

Telephone Number

Title/Position

Contractor/Company

Affected Corporate Branch/Division/Sector

Doing Business As

Contractor's Address

Street

City

Region

Country

Zip

Contractor's Telephone Number

Commercial and Government Entity Code (CAGE)

Data Universal Numbering System (DUNS)

Senior Corporate Point of Contact (POC)

First

Last

Suffix

Senior Corporate(POC) Telephone Number

Contract Number

Short Title

Contract Type

Contract Value

Description of Services/Supplies/System

Identify End Users

Contracting Officer Name*

First

Middle

Last

Suffix

Contracting Office Address

Street

City

Region

Country

Zip

Contracting Officer’s Telephone Number

Contract performance location

Street

City

Region

Country

Zip

Contracting Officer’s Technical Representative (COTR)

COTR Telephone Number

List all Federal agencies currently doing business with

Date Contractor learned of potential violation

Provide a full description of the nature of the violation(s) being disclosed

Including the period during which the violation occurred, names of individuals involved and an explanation of their roles in the allegations and the relevant periods of their involvement

Safety or operational hazards

Measures taken to mitigate safety or operational hazards

Estimated financial impact to the Government

Did an overpayment occur

Estimated amount of overpayment

Has an investigation been conducted

Describe the scope of the investigation

Records reviewed, number and positions of employees interviewed, etc.

Is the company willing to provide a copy of the investigative report

Measures taken to prevent recurrence

Submit

Office of Inspector General, United States Department of Defense, 4800 Mark Center Drive, Alexandria, VA 22350-1500

Official Submitting Disclosure

Contractor Data

Affected Contract

Disclosure, Overpayments, and Company Internal Investigation

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