Whistleblower's Questionnaire

Please answer the following questions as thoroughly as possible to help us determine whether or not we may be able to represent you. Please also send us anything else that might be helpful, such as supporting documents or a narrative you prepared. Any information that you submit will be held strictly confidential. Any of the Whistleblower Action Network attorneys may review and respond to your submission.

You may submit this form, and any attachments, by our secure email. However, total security and confidentiality of anything submitted via the internet cannot be guaranteed. If concerned, please print out the completed form and mail it to us at:

Whistleblower Action Network
500 N. Michigan Ave.
Suite 850
Chicago, IL 60611
(312) 327-0266 FAX

IMPORTANT: Before completing this form, please review our Checklist for Potential Relators

Part A. About You

Name: *

Address: *

Daytime phone: *

Evening phone:

Email address: *

Preferred method of contact: *

Daytime phone

Evening phone

Current employer:

Employer’s city and state:

Type of business:

Your job title/position:

Part B. About the Fraud

Name and address of the company that you believe is involved in the fraudulent activity:

Please describe the acts or activities that are fraudulent. You may attach additional pages if necessary:

Name, title and address of the person or persons you believe are committing fraud as well as a description of their participation:

Is the fraud being committed against a federal or state (or in the cases of NYC or Chicago), local government or agency? Which are:

Has this fraud previously been the subject of any legal actions or media? If yes, please describe:

How did you find out about the fraud and when?:

When did the fraud begin and how long has it been going on?:

Is the fraud still occurring?:

Yes

If not, when did it end?:

What is the approximate dollar value of the fraud and how did you calculate that number?:

Do you have any documentation of the fraud? If so, please describe:

If the person or entity committing fraud is not your employer, how did you learn about the fraud?:

Have you reported the fraud to anyone? If so, to whom did you report it, when, and what was their response?:

Have you discussed the fraud with anyone? If so, who, when, and what was their response?:

Is the person or entity able to pay a settlement or a court judgment? If so, how do you know?:

Have you ever filed a lawsuit before? If so, please describe the case:

Part C. Next Steps

What would you like us to do to help you?:

Please remember that submitting this form does not mean that any of the Whistleblower Action Network attorneys have agreed to represent you. While the information you have provided is privileged and confidential, we do not represent you until we enter into a written agreement.

We will review your submission based on the information you provide to determine whether you have a viable claim and make decisions about whether to accept your case based on thorough investigation of the facts and the law.

These investigations can be time consuming because we must analyze the facts and applicability of the False Claims Act to your specific potential claims.

If there is a reason we must immediately review your questionnaire, please let us know. As with any legal matter, the passage of time may affect your ability to assert your claims. Due to our thorough investigative approach and the number of inquiries we receive, we may not be able to assess your claim within your desired time frame. If our time constraints do not fit your needs, you should consult other counsel. Please understand that the statute of limitations for the False Claims Act can be as short as six years.

After reviewing the Checklist for Potential Relators and all of your responses above, please sign and date below to indicate your acceptance of these terms. Thank you for your inquiry.

Name:

Date:

I understand the terms of this disclaimer before proceeding: *

Yes