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Warning: Your Contractor Disclosure has NOT been submitted yet. You will need to complete thru Step 8. If you need to change any information, you can go back to previous step by clicking above Step 1 link.
A. Official Submitting Disclosure (STEP 1)
* A.1 Name
*
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* A.2 Address
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* A.3 Telephone Number
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*A.4 Title/Position

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*A.5 Email



B. Contractor Data (STEP 2)
* B.1 Contractor Name

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B.2 Affected Branch/Division/Sector

B.3 Doing business as (DBA)

* B.4 Contractor Address
* Address

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* City

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* State

* Zip
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* B.5. Telephone Number
*Phone Number

Phone Extension
B.6. Commercial and Government Entity Code(CAGE)

B.7. Data Universal Numbering System(DUNS)

B.8. Senior Corporate Point of Contact(POC)
Last

First

MI
B.9. Senior Corporate Point of Contact(POC) Telephone Number
Phone Number

Phone Extension
C. Affected Contracts (STEP 3)
Contract #1
* C.1 Contract Number

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C.2 Short Title

C.3 Contract Type

C.4 Contract Value

C.5 Description of Services/Supplies/System


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C.6 Identify End Users

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* C.7 Contracting Officer Name
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* C.8 Contracting Officer Address
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C.8.1 Contracting Officer Telephone Number
* C.9 Contract Performance Location
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C.10 Contracting Officer Technical Representative(COTR)
C.11 COTR Telephone Number
C.12 List all Federal Agencies currently doing business with(i.e. Veteran's Administration, General Services)

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D. Disclosure (STEP 4)
* D.1 Date contractor learned of potential violation
* D.2 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 period of their involvement

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* D.3 Safety and/or Operational Hazard?

If yes, please explain:

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D.4 Estimated financial impact to the government
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E. Overpayment (STEP 5)
* E.1 Did overpayment occur?
E.2 Estimated amount of overpayment
$
F. Company Internal Investigation (STEP 6)
* F.1 Has an investigation been conducted?
F.2 Describe the scope of the investigation(records reviewed, number and positions of employees interviewed, etc.)

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* F.3 Is the company willing to provide a copy of the investigative report?
F.4 Measures taken to prevent recurrence

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G. Attachments (STEP 7)
If you have supporting documentation that you wish to provide with this disclosure, please use the 'Upload Document' field below.
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H. Additional Information (STEP 8)
H.1 Additional Information

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I. Acknowledgements (STEP 9)

I state that this Contractor Disclosure Program submission is true and accurate to the best of my knowledge as of the date of its submission.



I understand and acknowledge that the submission of the foregoing Contractor Disclosure does not bar, prohibit, foreclose or preclude the Government from pursuing any and all criminal, civil and/or administrative remedies provided to it by law and/or regulation against (a) the business entity(ies) making the foregoing Contractor Disclosure Program submission, (b) any other business entities mentioned in the submission and/or (c) any individuals mentioned in the submission.
A. Official Submitting Disclosure (STEP 1)
Full Name
Address
Telephone Number
Title/Position
Email
B. Contractor Data (STEP 2)
Contractor Name
Affected Corporate Branch/Division/Sector
Doing Business as(DBA)
Contractor's Address
Telephone Number
Commercial and Government Entity Code(CAGE)
Data Universal Numbering System(DUNS)
Senior Corporate Point of Contact(POC)
Senior Corporate POC Telephone Number
D. Disclosure (STEP 4)
Date Contractor learned of potential violation(DD/MM/YYYY)
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
E. Overpayments (STEP 5)
Did an overpayment occur?
Estimated amount of overpayment
F. Company Internal Investigation (STEP 6)
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
G. Attachments (STEP 7)
    H. Additional Information (STEP 8)