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Anonymously Report Fraud Form

This form is designed to anonymously provide information that can be helpful in an inquiry of the questionable activity. Do not be concerned if you cannot complete the form in its entirety; however, provide as much information as you can. You also may download and print a copy of this form. This form does not track personally identifiable information.

1. Estimated date and time of activity:

2. Location where activity occurred:

3. Provide the names of any individuals who are involved in the questionable activity and how:

4. Estimated dollar amount of loss, if any:

5. Is the activity ongoing or could it potentially happen again (when)? Explain:

6. Explain or provide full description of the activity:

7. Describe any physical evidence or documentation available:

7a. Note: If physical evidence is in your possession only, can a copy be made available by mailing to Internal Audit Services, P O Box 750293, Dallas, TX 75275-0293

8. Describe how you became aware of the activity:

9. Does the suspect(s) know you are aware of the activity:

10. Explain why are you reporting activity:

11. Describe or define your relationship with the University (e.g., vendor, employee, etc.):

12. Are there other witnesses of the activity or have you reported the activity to other(s)? Explain:

13. Other or miscellaneous comments: