Submit Confidential Report

Note: Some whistleblower protection laws have deadlines as short as 30 days.

The National Whistleblower Legal Defense & Education Fund operates an Attorney Referral Service (ARS) to provide legal referrals to whistleblowers in search of competent counsel. The ARS is composed of attorneys from across the nation who are interested in whistleblower cases. To view additional resources that are available to you, click here. 

This form is intended to be used only to evaluate your claim and/or make a referral to legal counsel. It is not a commitment to provide legal representation.  Our organization is not affiliated with any government agency or court. Hitting the Submit button does not constitute the filing of a claim with any government agency or court. Regardless of our evaluation of your situation, the contents of the form shall remain confidential. If you do not wish to submit this form via email, you may use this printable form and send it via fax or US mail.

This form will be evaluated by attorneys for the National Whistleblower Legal Defense and Education Fund (“Fund”).  If you do not receive a response within 14 days please contact ek@whistleblowers.org. 

  * required fields
*First Name
*Last Name
*Address 1
Address 2
*City
*State
*Zip
*Phone Number
Fax
*Email
*List two large cities near your address:
*What is your preferred method of contact? Phone
Fax
E-mail
What do you want to report?
Name & address of employer where you experienced discrimination, reported or discovered fraud/misconduct and/or the employer for which you would like to make an initial fraud report:
*Are you currently employed? Yes
No
Position Title
If you have previously reported fraud or misconduct, when and to whom did you make this report? (Give specific dates)
*If applicable, when and what type of retaliation have you been subjected? (Give specific dates; details can be in your summary)
Are you reporting fraud committed at the expense of a governmental entity? Yes
No
If so, Name & Address of the Corporation, person or entity who made the false claim:
What agency has been defrauded?
Has there been a public disclosure of your case in any media? Yes
No
If yes, please describe where the disclosure occurred and when (Give specific dates; details can be in your summary):
Are you reporting tax fraud against the IRS? Yes
No
If so, Name & Address of the Corporation, person or entity who is responsible for the tax fraud:
Approximately how much money is involved in the fraud?
Has there been a public disclosure of your case in any media? Yes
No
If yes, please describe where the disclosure occurred and when (Give specific dates; details can be in your summary):
*Do you currently have an attorney? Yes
No
If so, please tell us the name and address of your attorney:
*Do you have a case pending before a court or an agency? Yes
No
If yes, give the name of your case and current status:
*Would you like an Attorney Referral? (An Attorney Referral does not necessarily result in attorney representation.) Yes
No
*Can the NWLDEF send a copy of this form to the referred attorney? Yes
No
*Can the NWLDEF discuss your case with members of the media? Yes
No
*Can the NWLDEF provide your e-mail address to the National Whistleblowers Center's Action Alert network in order to provide you with bulletins and updates on matters related to whistleblowing? Yes
No
How did you find out about the Attorney Referral Service? (Optional)
 
 

 

Thank You for Completing This Form. This form may be returned to the NWLDEF via e-mail, regular mail/federal express or by Fax to the following address:

Project Manager
National Whistleblower
Legal Defense & Education Fund
3238 P Street, N.W.
Washington, DC 20007
Facsimile (202) 342-1904

ars[at]whistleblowers[dot]org

Mark information with "Confidential Attorney Information." Please do not enclose any original documentation as documents will not be returned. You will be contacted if more information is needed.