Whistleblower Questionnaire

Submitted by dnowell on February 28, 2013

If you would like an attorney from The Chanler Group to evaluate your case on a privileged and strictly confidential basis for potential representation in a False Claims Act lawsuit, please provide the information requested below. In completing this questionnaire, be as detailed as possible, and attach any supporting documents. It is important that you provide information in writing so that our attorneys may properly assess the merits of your case.

After you complete the questionnaire, you may click the submit button, which will transmit your information through The Chanler Group’s encrypted electronic mail system. We at The Chanler Group understand the sensitivity of the situation created for you in coming forward. Because of this, our primary concern is to protect your confidentiality and the confidentiality of the information you provide. If you are especially concerned about protecting your identity and information, please contact us directly.

Terms and Conditions

Please be advised that the statute of limitations may be as short as six years for some claims under the False Claims Act. Your ability to bring a false claims action may be eliminated if someone else publicly discloses the same illegal conduct, files a false claims action regarding the same conduct, or causes the government to take action on the conduct before you file an action. If you become aware of any developments likely to go public that affect your claim, please contact us as soon as possible.

Please further be advised that you are responsible for keeping information about your claim confidential. Do not post any details or even references to your claim on any blog, online discussion forum, or any social networks such as Facebook or Twitter. Mentioning your claim on the Internet or in any other public forum may be detrimental to your claim.

Your communications with The Chanler Group, beginning with this questionnaire, are treated as privileged and confidential, although a formal attorney-client relationship will not automatically be created by submitting your information to The Chanler Group.

Your Name: *

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Fax:

Cell Phone:

Email:

What is the best time and method to contact you:

What is your profession/job title:

Who is your employer:

What companies or other entities do you believe are involved in the fraud againt the government:

What is the location (city and state) of the companies you believe are involved in the fraud:

What individuals do you believe were engaged in the fraud? What are their job titles or positions, and what role did those people play in the fraud:

When and how did you become aware of the fraud? When did the fraud begin? Has it ended? If so, when:

Please describe the nature of the fraud:

Did you have any involvement in the fraud? If so, please explain:

What is your estimate of the amount of money lost because of the fraud? Please describe how you arrived at this amount:

Have you discussed the fraud with anyone, including your employer, a local, state or federal government official or someone in the news media? If so, please state who you have discussed the matter with, and any response:

If you are no longer employed by the same company, are you considering legal action for wrongful termination? If so, describe any actions you have taken:

Has the fraud been disclosed during any part of a lawsuit, a congressional hearing or agency proceeding? If so, please describe:

Have you ever filed a lawsuit against any person or company before? If so, what was the nature of the lawsuit:

How did our firm come to your attention?:

Whistleblower Questionnaire

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