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Report Fraud, Waste, and Abuse Form
May we contact you regarding your submittal
«
?
Yes
No
How do We Contact You?
First Name:
Last Name:
Street Address:
Apt#.
City:
State:
Zip Code:
Home Phone:
Work Phone:
Ext:
E-Mail Address:
Contact Instructions:
Please include specific instructions on how to contact you. Indicate the best time of day that you can be reached and whether you would prefer to be contacted at home or at work. Because of the inherently unsecured nature of E-Mail, it is not recommended that E-Mail be used when transmitting sensitive or confidential information.
Tell Us About the Fraud, Waste or Abuse
Suspected Fraud, Waste or Abuse
«
:
...
Theft (cash, supplies, equipment)
Misuse of Equipment/Property (personal benefit)
Insurance Fraud (workers compensation, health)
Falsifying Records (inflated expense reports)
Contracts (bid-rigging, kickbacks, inflated costs)
Payroll Fraud (ghost employee, fictitious hours)
Payroll Abuse (inflated or unnecessary overtime)
Personnel Fraud (filing false application)
Procurment Fraud (fictitious vendor)
Procurement Violation (avoiding competitive bids)
Computer Fraud (hacking)Other (explain below)
County Agency
«
:
...
Administrative Office
Aging
Board of Appeals
Budget and Finance
Central Communication/911
Circuit Court
Community Colleges
Corrections
Economic Development
Employment and Training
Environmental Protection
Executive Office
Fire Department
Health Department
Housing Office
Human Resources
Information Technology
Law Office
Libraries
Liquor License Commisioners
Orphans Court
Permits and Development Mgmt
Planning and Community Conservation
Police Department
Public Schools
Public Works
Recreation and Parks
Sheriff
Social Services
State's Attorney
Supervisiors of Elections
Not Sure
Name of Person (if known):
When did It Occur?
Estimated $ Loss
«
:
.....
$1 - $500
$500 - $1,000
$1,000 - $10,000
$10,000 - $50,000
$50,000 - $100,000
$100,000 - $500,000
$500,000 - $1,000,000
over $1,000,000
unknown
Description of Fraud, Waste or Abuse
«
:
In order to process your allegation, it is important that you provide as much detail as possible, including: Who? What? When? Where? Why? How?
Important: Information in the fields marked with "
«
" are required.They must be filled in order to submit your information.
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Towson, MD 21204
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