Hhs Oig Contractor Self-Disclosure Form - U.s. Department Of Health And Human Services
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5HHS OIG CONTRACTOR SELF-DISCLOSURE FORM
A. OFFICIAL SUBMITTING DISCLOSURE
A.1. Name:
Last
First
MI
A.2. Address:
City
State
ZIP
A.3. Telephone Number:
ext.
A.4. Title/Position:
A.5. Email:
B. CONTRACTOR DATA
B.1. Contractor:
B.2. Affected Corporate
Branch/Division/Sector:
B.3. Doing Business As (dba):
B.4. Contractor’s Address:
City
State
ZIP
B.5. Telephone Number:
ext.
B.6. Commercial and
Government Entity Code
(CAGE):
B.7. Data Universal
Numbering System (DUNS):
B.8. Senior Corporate Point of
Contact (POC) :
Last
First
MI
B.8.1 Senior Corporate
ext.
Telephone Number:
C. AFFECTED CONTRACT
C.1. Number:
C.2. Short Title:
C.3. Contract Type:
C.4. Contract Value:
$
C.5. Description of Product/
Services/Supplies/System:
Check box if additional information on page 5, Section H.
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