2. CONFIDENTIAL INFORMATION
4. Any information reported on this form is confidential and will be kept confidential by Internal Audit in order to maintain the integrity of the Fraud, Waste & Abuse Hotline reporting and investigation process. Because this form, when completed, contains investigative notes and information furnished in confidence to Internal Audit, the completed form and its contents are excluded from mandatory disclosure under the Virginia Freedom of Information Act. Virginia Code § 2.2-3705.3(7); 2.2- 3700 et seq.
6. Reporting Method:
7. Source:
8. Allegation:
9. Disposition:
11. Subject of Call:
12. Entity:
13. Auditor:
14. Project Number:
16. OFFICE/INTERNAL USE ONLY
20. COUNTY OF HANOVER
22. Fraud, Waste & Abuse Reporting
24. You may fill-in this form on-screen and submit it directly to the Internal Audit Department by selecting the submit button at the bottom or you may select the print button and either fax the form to 804-365-6878 or mail the form to: Internal Audit Department, P.O. Box 470, Hanover, VA 23069-0470.
26. Date of Report:
    Date of Report:
27. Location of Incident:
29. Details of the incident(s) (who, what, where, when, how, etc):
31. Please list any suspected person(s) involved or having knowledge of incident in as much details as possible (such as names, departments, positions, contact information, etc):
33. What is the approximate dollar amount involved in the incident?
35. Please describe any evidence you have in as much details as possible (documents, photographs, etc.) Also include relevant ID numbers such as vehicle tag #, car make/model and equipment #:
37. How did you become aware of the incident(s)? (Examples: witness first hand, hear it from another person, etc.)
39. Please provide any other information which could assist our investigation:
43. We treat all information received as confidential. If you wish to remain anonymous, you may skip this section; however, we encourage you to provide this information in case we need to contact you for further information.
45. Your name:
46. Your email address:
48. Your phone number:
49. Your department/title:
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51. 1. Receive an email copy of this form.
52. Email address

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53. Submit Submit and Print

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