Qui Tam Complaint Under the False Claims Act

QUI TAM COMPLAINT UNDER THE FALSE CLAIMS ACT

31 U.S.C. § 3729-3733

UNITED STATES DISTRICT COURT

[DISTRICT NAME]

UNITED STATES OF AMERICA, ex rel.

[RELATOR'S FULL LEGAL NAME],

Plaintiff-Relator,

v.

[DEFENDANT COMPANY/INDIVIDUAL NAME],

Defendant(s).

Case No.: _________________________________

COMPLAINT FILED UNDER SEAL

JURY TRIAL DEMANDED

NOTICE OF FILING UNDER SEAL

This Complaint is filed IN CAMERA and UNDER SEAL pursuant to 31 U.S.C. § 3730(b)(2). The Complaint shall remain under seal for at least sixty (60) days and shall not be served on the Defendant(s) until the Court so orders.

PRELIMINARY STATEMENT

NATURE OF THE ACTION

☐ This is a qui tam action brought on behalf of the United States of America under the False Claims Act ("FCA"), 31 U.S.C. § 3729 et seq.

☐ Relator brings this action to recover treble damages and civil penalties arising from Defendant(s)' knowing submission of false or fraudulent claims to the United States Government.

☐ The fraudulent scheme described herein resulted in losses to the federal government estimated at: $__________________

I. PARTIES

A. Relator (Whistleblower)

Full Legal Name: _________________________________

Current Address: _________________________________

City, State, ZIP: _________________________________

Telephone: _________________________________

Email: _________________________________

Relationship to Defendant:
☐ Current Employee
☐ Former Employee (Dates of Employment: __________ to __________)
☐ Contractor/Subcontractor
☐ Competitor
☐ Other: _________________________________

Position/Title Held: _________________________________

Department/Division: _________________________________

Direct Knowledge of Fraud:
☐ Personal observation and participation in work
☐ Access to documents evidencing fraud
☐ Conversations with individuals involved in fraud
☐ Other: _________________________________

B. Defendant(s)

Defendant 1:

Name: _________________________________

Type of Entity:
☐ Corporation ☐ LLC ☐ Partnership ☐ Individual ☐ Other: __________

State of Incorporation/Formation: _________________________________

Principal Place of Business: _________________________________

Address: _________________________________

Defendant 2 (if applicable):

Name: _________________________________

Type of Entity:
☐ Corporation ☐ LLC ☐ Partnership ☐ Individual ☐ Other: __________

Address: _________________________________

Role in Fraudulent Scheme: _________________________________

(Add additional defendants as necessary)

II. JURISDICTION AND VENUE

☐ This Court has subject matter jurisdiction pursuant to 28 U.S.C. § 1331 (federal question) and 31 U.S.C. § 3732(a).

☐ This Court has personal jurisdiction over the Defendant(s) because:
☐ Defendant(s) reside(s) in this District
☐ Defendant(s) transact(s) business in this District
☐ Defendant(s) committed act(s) giving rise to this action in this District
☐ Defendant(s) can be found in this District

☐ Venue is proper in this District pursuant to 31 U.S.C. § 3732(a) and 28 U.S.C. § 1391(b) because:
☐ Defendant(s) reside(s) in this District
☐ A substantial part of the events giving rise to the claims occurred in this District
☐ Defendant(s) can be found in this District

III. FACTUAL ALLEGATIONS

A. Background of Defendant's Business

Describe the Defendant's business operations and relationship with the federal government:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

B. Federal Programs and Contracts Involved

Identify all federal programs, contracts, or grants affected:

☐ Medicare (42 U.S.C. § 1395 et seq.)
☐ Medicaid (42 U.S.C. § 1396 et seq.)
☐ Department of Defense contracts
☐ Department of Veterans Affairs contracts
☐ Small Business Administration programs
☐ Federal grant programs
☐ Other federal programs: _________________________________

Contract/Grant Numbers (if known): _________________________________

Contracting Agency: _________________________________

Contract Period: _________________________________

Approximate Contract Value: $__________________

C. The Fraudulent Scheme

1. Description of False Claims

Describe in detail the false or fraudulent claims submitted to the government:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

2. Type of False Claims Act Violation(s)

The Defendant(s) violated the FCA by (check all that apply):

☐ 31 U.S.C. § 3729(a)(1)(A) - Knowingly presenting, or causing to be presented, a false or fraudulent claim for payment or approval

☐ 31 U.S.C. § 3729(a)(1)(B) - Knowingly making, using, or causing to be made or used, a false record or statement material to a false or fraudulent claim

☐ 31 U.S.C. § 3729(a)(1)(C) - Conspiring to commit a violation of the FCA

☐ 31 U.S.C. § 3729(a)(1)(D) - Having possession, custody, or control of property or money used, or to be used, by the Government and knowingly delivering less than all of that money or property

☐ 31 U.S.C. § 3729(a)(1)(E) - Authorizing delivery of less than all money or property under a receipt

☐ 31 U.S.C. § 3729(a)(1)(F) - Knowingly buying, or receiving as a pledge of an obligation or debt, public property from an unauthorized person

☐ 31 U.S.C. § 3729(a)(1)(G) - Knowingly making, using, or causing to be made or used, a false record or statement material to an obligation to pay or transmit money or property to the Government (reverse false claims)

3. Knowledge and Intent

Defendant(s) acted with the requisite knowledge as defined by 31 U.S.C. § 3729(b)(1):

☐ Actual knowledge - Defendant(s) had actual knowledge of the falsity of information

☐ Deliberate ignorance - Defendant(s) deliberately ignored the truth or falsity of information

☐ Reckless disregard - Defendant(s) acted in reckless disregard of the truth or falsity of information

Evidence supporting knowledge/intent:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

4. Materiality

The false statements and claims were material to the government's payment decision because:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

5. Timeline of Fraudulent Conduct

D. Specific Examples of False Claims

Example 1:

Date of Claim: _________________________________

Description: _________________________________

Amount: $__________________

How Claim Was False: _________________________________

Example 2:

Date of Claim: _________________________________

Description: _________________________________

Amount: $__________________

How Claim Was False: _________________________________

Example 3:

Date of Claim: _________________________________

Description: _________________________________

Amount: $__________________

How Claim Was False: _________________________________

(Add additional examples as necessary)

E. Damages to the Government

Estimated total amount of false claims submitted: $__________________

Period during which false claims were submitted: __________ to __________

Number of false claims submitted (if known): __________________

Method used to calculate damages:

_____________________________________________________________________________

_____________________________________________________________________________

IV. ORIGINAL SOURCE DECLARATION

Pursuant to 31 U.S.C. § 3730(e)(4), Relator is an "original source" of the information on which the allegations in this Complaint are based.

Relator's basis for knowledge:

☐ Direct and independent knowledge of the information

☐ Voluntary disclosure to the Government prior to any public disclosure

How Relator obtained this information:

☐ Through employment with Defendant
☐ Through access to Defendant's records and documents
☐ Through direct observation of fraudulent conduct
☐ Through conversations with Defendant's employees
☐ Other: _________________________________

Specific facts supporting original source status:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

V. PUBLIC DISCLOSURE BAR ANALYSIS

☐ There has been no public disclosure of the allegations or transactions in this Complaint through any of the following:
☐ Federal criminal, civil, or administrative hearings
☐ Congressional, administrative, or Government Accountability Office reports, hearings, audits, or investigations
☐ News media

☐ If there has been a public disclosure, Relator qualifies under the "original source" exception because:

_____________________________________________________________________________

_____________________________________________________________________________

VI. COMPLIANCE WITH FILING REQUIREMENTS

A. Service on the Government

☐ Simultaneously with the filing of this Complaint, Relator is serving on the Attorney General of the United States and the United States Attorney for this District:

☐ A copy of this Complaint

☐ A written disclosure statement containing substantially all material evidence and information Relator possesses

B. Seal Requirements

☐ Relator understands this Complaint shall remain under seal for at least 60 days pursuant to 31 U.S.C. § 3730(b)(2)

☐ Relator will not disclose the filing of this action except as necessary to comply with seal requirements

VII. CLAIMS FOR RELIEF

COUNT I: Violation of 31 U.S.C. § 3729(a)(1)(A)

False Claims

1. Relator re-alleges and incorporates by reference all preceding paragraphs.

2. Defendant(s) knowingly presented, or caused to be presented, false or fraudulent claims to the United States Government for payment or approval.

3. By reason of Defendant(s)' acts, the United States has been damaged in an amount to be determined at trial.

COUNT II: Violation of 31 U.S.C. § 3729(a)(1)(B)

False Statements

1. Relator re-alleges and incorporates by reference all preceding paragraphs.

2. Defendant(s) knowingly made, used, or caused to be made or used, false records or statements material to false or fraudulent claims.

3. By reason of Defendant(s)' acts, the United States has been damaged in an amount to be determined at trial.

COUNT III: Violation of 31 U.S.C. § 3729(a)(1)(C)

Conspiracy

(Include if applicable)

1. Relator re-alleges and incorporates by reference all preceding paragraphs.

2. Defendant(s) conspired with others to commit violations of 31 U.S.C. § 3729(a)(1)(A) and/or (B).

3. By reason of Defendant(s)' conspiracy, the United States has been damaged in an amount to be determined at trial.

VIII. PRAYER FOR RELIEF

WHEREFORE, Relator, on behalf of the United States of America, respectfully requests that this Court:

☐ Enter judgment against Defendant(s) in the amount of three times the damages sustained by the United States, pursuant to 31 U.S.C. § 3729(a)(1)

☐ Impose civil penalties of not less than $14,308 and not more than $28,619 for each false claim submitted, pursuant to 31 U.S.C. § 3729(a)(1) (as adjusted for inflation)

☐ Award Relator the maximum percentage of proceeds allowable under 31 U.S.C. § 3730(d):

• If the Government intervenes: 15-25% of the recovery
• If the Government does not intervene: 25-30% of the recovery

☐ Award Relator reasonable attorneys' fees, expenses, and costs pursuant to 31 U.S.C. § 3730(d)

☐ Grant such other and further relief as the Court deems just and proper

IX. JURY DEMAND

Relator demands a trial by jury on all issues so triable.

VERIFICATION

I, _________________________ [Relator's name], declare under penalty of perjury under the laws of the United States of America that:

1. I have read the foregoing Complaint and know its contents.

2. The factual allegations contained herein are true and correct to the best of my knowledge, information, and belief.

3. I am an original source of the information contained in this Complaint.

4. I have not derived the allegations herein from a public disclosure.

Executed on: _________________________________

Location: _________________________________

_____________________________________________
Signature of Relator

ATTORNEY CERTIFICATION

I, the undersigned attorney, certify that:

☐ I am admitted to practice before this Court

☐ I have conducted a reasonable inquiry into the facts and law supporting this Complaint

☐ The allegations and claims herein are warranted by existing law or a good faith argument for extension, modification, or reversal of existing law

☐ I have served a copy of this Complaint and written disclosure on the Attorney General and the United States Attorney as required by 31 U.S.C. § 3730(b)(2)

Attorney Name: _________________________________

Bar Number: _________________________________

Firm Name: _________________________________

Address: _________________________________

Telephone: _________________________________

Email: _________________________________

Date: _________________________________

_____________________________________________
Attorney Signature

STATE-SPECIFIC NOTES

California

California has its own False Claims Act (Cal. Gov. Code § 12650-12656) that applies to fraud against state and local governments. Qui tam actions may be brought under both federal and California state law for overlapping claims. California allows recovery of treble damages plus civil penalties of $5,500-$11,000 per claim.

New York

New York State False Claims Act (State Finance Law § 187-194) provides for qui tam actions involving fraud against the state. New York has a tax-specific False Claims Act provision. The state law is closely modeled on the federal FCA.

Texas

Texas Medicaid Fraud Prevention Act (Tex. Hum. Res. Code § 36.001 et seq.) allows qui tam actions for Medicaid fraud. Texas Government Code Chapter 2107 addresses fraud involving other state funds. The Texas Attorney General's Medicaid Fraud Control Unit handles investigations.

Florida

Florida False Claims Act (Fla. Stat. § 68.081-68.092) provides for qui tam actions against those who defraud the state. The statute covers fraud involving state funds, including Medicaid. Civil penalties range from $5,500 to $11,000 per claim plus treble damages.

ATTACHMENTS CHECKLIST

☐ Written Disclosure Statement (substantially all material evidence)
☐ Copies of relevant documents (redacted as necessary)
☐ Timeline of fraudulent conduct
☐ List of potential witnesses
☐ Calculation of damages
☐ Civil cover sheet
☐ Summons

IMPORTANT NOTICES

SEAL REQUIREMENTS: This action is filed under seal and must remain under seal for at least 60 days. Disclosure of this action during the seal period may result in dismissal and/or reduction of the relator's share.

STATUTE OF LIMITATIONS: Under 31 U.S.C. § 3731(b), an FCA action must be brought within the later of: (1) 6 years after the violation occurred; or (2) 3 years after the date when facts material to the action were known or reasonably should have been known, but in no event more than 10 years after the violation.

CURRENT PENALTIES (2025-2026): Civil penalties are adjusted annually for inflation. As of 2025, penalties range from approximately $14,308 to $28,619 per false claim. Verify current penalty amounts at time of filing.

This template is provided for educational purposes only. False Claims Act litigation is highly specialized and requires experienced legal counsel. Failure to comply with procedural requirements may result in dismissal of the action or reduction of the relator's award.