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NRO Corporate Disclosure Record

*Asterisk () Denotes Mandatory Entry**
A. Disclosure Point of Contact
*A.1. Name (First, MI, Last)
A.2. Position/Title:
A.3. Company Name:
A.4. POC Company Address:
*A.5. POC Company Telephone Number:
A.6. POC Company Email Address:

B. Affected Company Data
B.1. Company Name (if different from above):
B.2. Affected company branch/division/sector:
B.3. Affected branch/division/sector address:
B.4. POC Telephone Number

C. Affected Contract(s)
C.1. Contract Number(s):

D. Disclosure
D.1. Date company learned of potential violation:
D.2. Is the subject(s) aware of the allegation?	(Yes/No)
D.3. Has any external legal counsel been notified?	(Yes/No)
*D.4. Brief description of the nature of the violation(s) being disclosed, including the information forming the basis of this report, dates, locations, how the matter was discovered/disclosed to the company; and actions taken against the subject (i.e. still employed, etc.):
Note: Please include any safety issues that are related to this disclosure. Access the OIG website on the NRO Contractor Wide Area Network or send the information to the IG via classified fax: (703) 808-1856 (Attn: Assistant IG for Investigations) if your information involves any classification issues.

E. Overpayment
E.1. Did an overpayment occur?	(Yes/No)
E.2. Amount of overpayment:

F. Corporate Investigation
F.1. Has an investigation/inquiry/review been initiated?	(Yes/No)


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