Legal Fraud Report Template

LEGAL FRAUD REPORT TEMPLATE

This Legal Fraud Report (the "Report") is submitted by Reporting Party: , Contact Person: , Contact Phone: , and is submitted concerning Alleged Respondent: , Position/Role: . Date of Report: .

RECITALS

WHEREAS, Reporting Party has reason to believe that certain actions, omissions or transactions involving Alleged Respondent may constitute fraud, misrepresentation, theft, embezzlement, or related improper conduct (collectively, the "Alleged Conduct"); and

WHEREAS, Reporting Party desires to document the facts, preserve and describe evidence, identify witnesses, and place the Alleged Conduct on record so that appropriate internal, civil, or criminal proceedings may be pursued; and

WHEREAS, Alleged Respondent occupies the position set forth above and may have had access or authority relevant to the transactions or records described herein.

NOW THEREFORE, in consideration of the foregoing recitals and the mutual covenants set forth below, Reporting Party provides the following report and certifications.

1. REPORTED INCIDENT

Date of Alleged Incident: . Location of Alleged Incident:

Internal audit or reconciliation Tip or complaint Management review Other

2. PARTIES & ROLES

3. INVESTIGATION & REPORTING STATUS

Internal investigation opened: Yes No If yes, Investigator / Team:

Reported to external counsel: Yes No Reported to law enforcement: Yes No

4. CONFIDENTIALITY AND PROTECTIONS

Reporting Party requests that this Report and all materials provided in connection herewith be treated as confidential to the fullest extent permitted by law. To the extent applicable, the Reporting Party shall be afforded whistleblower and non-retaliation protections under the policies of the Reporting Party and applicable law. The Reporting Party acknowledges that certain disclosures must be made to investigators, auditors, regulators or law enforcement where required by law or where necessary to effectuate an investigation.

Request confidential treatment: Yes No

5. CERTIFICATIONS

By signing below, the undersigned certifies under penalty of perjury that the information contained in this Report, to the best of the undersigned's knowledge, is true, complete and accurate, and that the undersigned will promptly provide any additional information or documents within the undersigned's possession that may be requested by investigators or authorities. The undersigned understands that knowingly submitting false statements in connection with a fraud report may subject the undersigned to civil and criminal penalties.

Certification of truthfulness: I certify that the foregoing is true and correct to the best of my knowledge.

6. NOTICES

All notices or communications required or permitted under this Report shall be in writing and shall be delivered to the contact details set forth below for each party.

7. GOVERNING LAW; MISCELLANEOUS

Governing Law: This Report shall be governed by and construed in accordance with the laws of the jurisdiction in which Reporting Party has its principal place of business, without regard to principles of conflicts of law.

Entire Agreement: This Report constitutes the complete written record of the matters set forth herein and supersedes all prior communications and understandings, whether oral or written, with respect to the subject matter herein.

Severability: If any provision of this Report is held invalid or unenforceable, the remaining provisions shall remain in full force and effect, and the invalid provision shall be reformed only to the extent necessary to make it enforceable.

Amendments and Waiver: No amendment, modification or waiver of any provision of this Report shall be effective unless in writing and signed by the party against whom enforcement is sought. No waiver by any party of any breach shall be deemed a waiver of any subsequent breach.

Counterparts: This Report may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

Sign Now