Fraud Report

1. Please describe your fraud, waste or abuse concern in as much detail as possible:

2. Please provide the specific or approximate time this fraud, waste and or abuse occurred and identify if it is occurring now:

3. Please identify the location to which your report of fraud, waste and or abuse pertains. Be specific as possible to assist in the investigation that will follow your report:

4. What actions, facts or set of circumstances occurred that led you to feel the need to report these concerns of fraud, waste and or abuse?

5. Please identify the individual(s) involved in the fraud, waste and or abuse:

6. What type of documentation are you able to provide in relation to this report or fraud, waste and abuse?e.g. copies, photos, examples, schedules.

7. What is the approximate dollar amount involved in this possible fraud, waste and or abuse?

8. Please provide any other information which could assist in reviewing your report of fraud, waste and or abuse:

You can remain anonymous. However, if you would like to identify yourself, please fill out the following information, knowing your privacy is not guaranteed:

Name:

E-mail Address:

SUBMIT REPORT TO HENRICO INTERNAL AUDIT