Confidential Case Evaluation Form

While we would strongly encourage you to call or see us about your case, if you would like Hodgson Russ to review your potential False Claims Act case and consider representing you in bringing a lawsuit, please read and fill out this form. You can return it by e-mail or by regular mail at the address below. We are legally and ethically bound to keep this form and our discussions with you confidential, and to treat them as privileged.

Internet Security: E-mail sent to us by using this form is encrypted. As with all encrypted e-mail, complete security cannot be guaranteed. If you are concerned about submitting this form by e-mail, please print it out and mail it to us at:

Dan Oliverio
Hodgson Russ LLP
The Guaranty Building
140 Pearl Street, Suite 100
Buffalo, New York 14202
e-mail: doliverio@hodgsonruss.com

No attorney-client relationship/no legal advice: By submitting this form, you agree that the exchange of information through this form, including any follow-up communications, does not create a lawyer-client relationship. That relationship begins only when you expressly hire us, we agree to that representation, and you and we both sign an engagement letter. You also agree that nothing in this form or on our Web site constitutes legal advice to you.

Follow-up: Please be sure to provide us with a way to contact you (a home e-mail address or a home or mobile phone number). If you provide no contact information, please be sure to follow up with us soon after you submit this form to discuss your potential case.

Please do not communicate with us using your employer's e-mail system or your work e-mail address.

1) Today's Date:

2) Name: (optional)

3) Home address: (optional)

4) Home or mobile phone number, with area code: (optional)

5) Home e-mail address: (optional)

6) Home state: (if you omitted your home address above)

7) Employer:

8) Position:

9) Name(s) of the company, companies, and/or individuals involved:

10) Their locations:

11) Have you ever worked for it/them? When? Title(s):

12) Which government(s) (federal,state,local) is involved?:

13) Provide a brief description of the issue you believe involves a fraud upon the government:

14) How did you learn about this issue?:

14 a) When did you learn about it?:

15) Besides those involved in it, who else knows about this issue?:

16) Have you discussed this issue with anyone?: YES NO

16 a) Who?:

16 b) When?:

17) Have you reported this issue to someone at the company?: YES NO

18) Have you consulted another attorney on this issue?: YES NO

19) When did this first occur? When did it end?:

20) What records or documents do you have, or have access to, that substantiate this issue?:

21) Have there been any public disclosures of this issue?: YES NO

21 a) If so, explain:

22) Who are the individuals involved in, or responsible for, this issue?:

22 a) How do you know?:

23) Do you know of anyone other than you who might be considering filing a false claims act lawsuit about this issue?:

24) Do you know of anyone who might be considering making this issue public, or otherwise making it known to the government?:

25) What is your estimate of the number of transactions by which the government has been defrauded this way?

26) What is your estimate of the total dollar value by which the government has been defrauded this way?

27) How did you arrive at this estimate?:

28) What is your estimation of the financial condition of the company at issue to pay a false claims act judgment or settlement?:

29) Please list all other lawsuits you have been involved in as a plaintiff, defendant, or witness: