FALSE CLAIMS ACT INQUIRY FORM*

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Burkhalter, Rayson & Associates, P.C.

P.O. Box 2777

Knoxville, TN 37901-2777

Fax No.: (865) 524-0172

To request more information, please complete the form below.
*Bold fields are required*

*Email:*

*Your Name*

*Date:*

What is the nature of the deceitful act(s) used to improperly obtain money from the U.S. Government or other non-compliance issue? Please describe/explain.

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 occurring in order to obtain money from the U.S. Government:

*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?

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

*Your home phone:*

Work Phone:

Other Phone:

*Your mailing address ( street, city, st and zip ):*

*When and how did you hear about us?*

Your information is being sent directly to Burkhalter, Rayson & Associates, P.C., and by law, all communications to us are 100% confidential.

*If we take the case, we will ask you to enter into a written agreement as to our fee, (which attorneys call a “contingency fee” since payment is contingent upon winning).