1). Identify the type of fraud you are reporting, e.g. theft of goods or services by a government official or employee. Choose from the following:

. Theft of funds by a government employee or official Corruption in the administration of a government program/public assistance program Filing of a false personal injury or property damage claim against the city Corruption or irregularity in the contract award process Fraud committed by a business contracting with a government agency Other

2). Please provide a precise description of the fraudulent activity, including the name of any city department, program or service wherein you believe fraud is taking place; the name of the individual or business entity whom you believe is involved in fraudulent activity; and details of the incident(s) you are reporting.

3). If these allegations are related to a claim or to a contract, please provide the claim or contract number, if known.

4). Date the incident occurred (Month/Day/Year):

5). Where the incident occurred:

6). What is the basis of your knowledge regarding these matters (e.g. you witnessed these acts first-hand; you work where the fraud is occurring; you have been told by others with first-hand knowledge; etc.)?

7). Do you have any evidence such as documents, photographs, letters, electronic data, or anything else to substantiate the fraud? Describe.

8). Can we contact you to discuss your concerns in more detail?
yes
no

If yes, please provide a way we can contact you below. (You may provide as much or as little information as you wish.)

Name:

Address:

Telephone Number:

Enter Email Address or Leave as Is to Send Anonymously:

9). Would you be willing to come into our office to give a statement?
yes
no