False Claims Inquiry Form - The Burkhalter Law Firm

Todays Date *

Name *

First

Last

Address (Street, City, State, & Zip Code) *

Email *

Contact Phone Number *

When is the best time to contact you, and how would you prefer we contact you?

What is the nature of the deceitful act(s) used to improperly obtain money from the U.S. Government and/or a State Government

What company is committing this deceitful act(s)? (If you prefer, you do not have to provide the company name at this time)

What states does the company do business in?

When did these deceitful act(s) begin? Are they still going on?

Have you filed any complaint about this situation or has anyone else filed a complaint to your knowledge? If so, please explain:

How did you obtain knowledge of this deceitful activity?

Do you have documents or written proof of the deceitful activity? If so, please describe the types of documents you have that will prove the deceitful activities.

Are there witnesses who would testify concerning this deceitful activity? If so, would they be able to support your allegations?

What is the approximate dollar amount involved in the deceitful activity?

If we take this case, what result would you like to see accomplished?

Any other facts you would like us to know?

Do you have questions or concerns?

How did you hear about us?

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