Form NHTSA Form 1686 NHTSA Form 1686 FORM WB-AWARD WHISTLEBLOWER AWARD APPLICATION

Appendix C to Part 513- Form WB-AWARD

OMB Number: 2127-0767

Exp. [DATE]

NHTSA Form 1686

UNITED STATES DEPARTMENT OF TRANSPORTATION

NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION (NHTSA)

FORM WB-AWARD

WHISTLEBLOWER AWARD APPLICATION

See Privacy Act Statement, Submission Procedures, and Completion Instructions below.

A. CLAIMANT’S INFORMATION (REQUIRED FOR ALL SUBMISSIONS)
1. Last Name		2. First Name				3. M.I.
4. Street Address							5. Apartment/Unit #
6. City	7. State/Province			8. ZIP/Postal Code					9. Country
10. Telephone	11. Alt. Phone			12. Email Address					13. Preferred Method of Communication
B. LEGAL REPRESENTATIVE INFORMATION (If Applicable – See Instructions)
1. Legal Representative’s Name
2. Firm Name
3. Street Address
4. City			5. State/Province		6. ZIP/Postal Code			7. Country
8. Telephone			9. Email Address

C. ELIGIBILITY REQUIREMENTS AND OTHER INFORMATION

1. Did you acquire the original information that you submitted to NHTSA solely through a communication that was subject to the attorney-client privilege or attorney work product doctrine?

[] Yes [] No

2. Did you acquire the original information that you submitted to NHTSA by a means or manner that was determined by a United States federal court or state court to violate applicable federal or state criminal law?

[] Yes [] No

3. Are you currently a subject or target of a criminal investigation in the United States, or have you been convicted of a criminal violation by a United States federal or state court, in connection with the allegations or conduct that you submitted to the NHTSA?

[] Yes [] No

4. Indicate whether any of the factors in 49 CFR 513.7 apply, which could make you ineligible for an award.

[] Yes [] No

5. If you answered “Yes” to any of Questions above, provide details. Use additional sheets, if necessary.

D. ISSUE DETAILS

1. How did you submit original information to NHTSA?

[] By email to [email protected]

[] Other: _____________________

2. Date(s) that you submitted the information:

3. Name of motor vehicle manufacturer, part supplier and/or dealership to which this issue relates

E. NOTICE OF COVERED ACTION AND RELATED ACTION

1. Date of relevant Notice of Covered Action

2. Notice Number

3. Case Name

4. Case Number

5. Date of relevant Notice of Covered Action for any related action

6. Notice Number of Related Action

7. Case Name of Related Action

8. Case Number of Related Action

F. AWARD JUSTIFICATION

Explain the basis for your belief that you should receive an award in connection with your submission of information to NHTSA. Specifically address how you believe you voluntarily provided NHTSA with original information that led to the successful resolution of a covered action. Provide any information that you think may be relevant in light of the criteria for determining the amount of an award set forth in 49 U.S.C. § 30172 and 49 C.F.R. Part 513. Use additional sheets, if necessary.

G. CLAIMANT’S DECLARATION
I declare under penalty of perjury under the laws of the United States that the information contained herein is true and correct to the best of my knowledge, information and belief. I fully understand that I may be subject to prosecution and ineligible for a whistleblower award if, in my submission of information or other interactions with the National Highway Traffic Safety Administration, or my dealings with another authority in connection with a related action, I knowingly and willfully make any false, fictitious or fraudulent statements or representations, or use any false writing or document knowing that the writing or document contains any false, fictitious or fraudulent statement or entry.
Print Name
Signature	Date

Privacy Act Statement

The Privacy Act of 1974 requires that the National Highway Traffic Safety Administration (“NHTSA”) inform individuals of the following when asking for information. This form may be used by an employee or contractor of a motor vehicle manufacturer, part supplier, or dealership, or a legal representative acting on such person’s behalf, who wishes to apply for a whistleblower award for providing original information that led to the successful resolution of a covered action. The information provided will allow the Agency to evaluate the claim and elicit information relevant to whistleblower eligibility requirements. Furnishing the information is voluntary but a decision not to do so will result in you not being eligible for award consideration.

Questions concerning this form may be directed to the National Highway Traffic Safety Administration, Office of the Chief Counsel by email to [email protected] or a NHTSA attorney with whom you have previously been in contact.

General Information

• This form should be used by persons making a claim for a whistleblower award in connection with information provided to NHTSA. To be eligible for an award, you must meet all the requirements set forth in 49 U.S.C. § 30172 and the rules thereunder, as contained in 49 CFR Part 513.

• You must sign the WB-AWARD form as the claimant. If you provided your information to NHTSA anonymously, you must now disclose your identity on this form and your identity must be verified in a form and a manner that is acceptable to the Agency prior to the payment of any award.

• Your WB-AWARD form, and any attachments thereto, must be received by NHTSA within ninety (90) days of the date of the Notice of Covered Action to which the claim relates.

• You must submit your form to NHTSA in one of following two ways: emailing it to [email protected] or by any such method that the Agency may expressly designate on its website (https://www.nhtsa.gov/laws-regulations/whistleblower-program).

Instructions for Completing Form WB-AWARD

Section A: Claimant’s Information

Questions 1-13: Please provide the following information about yourself:

• Last name, first name, and middle initial;

• Your complete address, including city, state/province, zip/postal code, and country;

• Your telephone number, and if available, an alternate number where you can be reached;

• Your email address (to facilitate communications, you are strongly encouraged to provide your email address); and

• Your preferred method of communication.

Section B: Legal representative Information. Complete this section only if you are represented by a legal representative in this matter. If you are not represented by a legal representative in this matter, leave this Section blank.

Questions 1-9: Provide the following information about the legal representative representing you in this matter:

• Your legal representative’s name;

• The firm name;

• Your legal representative’s complete address, including city, state, and zip code;

• Your legal representative’s telephone number; and

• Your legal representative’s email address.

Section C: Eligibility Requirements and Other Information

Question 1: Indicate whether you acquired the original information that you submitted to NHTSA solely through a communication that was subject to the attorney-client privilege or attorney work product doctrine.

Question 2: Indicate whether you acquired the original information that you submitted to NHTSA by a means or manner that was determined by a United States federal court or state court to violate applicable federal or state criminal law.

Question 3: Indicate whether you are currently a subject or target of a criminal investigation in the United States or whether you have been convicted of a criminal violation by a United States federal or state court in connection with the allegations or conduct that you submitted to NHTSA.

Question 4: Indicate whether any of the factors in 49 CFR 513.7 apply, which could make you ineligible for an award.

Question 5: If you answered “yes” to Questions 1, 2, 3, or 4 above, provide details. Use additional sheets if necessary.

Section D: Whistleblower Information Details

Questions 1-3: Provide the following information about the whistleblower information that you submitted to NHTSA:

• Select the method by which you submitted original information to NHTSA. If you selected “Other” describe how you submitted the information;

• Provide the date that you submitted the original information to NHTSA; and

• Provide the name of the motor vehicle manufacturer, part supplier, and/or dealership to which the issue relates.

Section E: Notice of Covered Action

The process for making a claim for a whistleblower award begins with the publication of a “Notice of Covered Action” on NHTSA’s website. This notice is published whenever a judicial or administrative action brought under 49 U.S.C. Chapter 301 by NHTSA, the U.S. Department of Transportation, or the U.S. Department of Justice results in collected monetary sanctions exceeding $1,000,000.

A Notice of Covered Action is published on NHTSA’s website subsequent to the entry of a final judgment, order or agreement that by itself, or collectively with other judgments, orders or agreements previously entered in the action, results in collected monetary sanctions exceeding the $1,000,000 threshold.

Question 1: Provide the date of the Notice of Covered action to which this claim relates.

Question 2: Provide the notice number of the Notice of Covered Action.

Question 3: Provide the case name referenced in the Notice of Covered Action.

Question 4: Provide the case number referenced in the Notice of Covered Action.

Question 5: Provide the date of the relevant Notice of Covered Action for any related action.

Question 6: Provide the notice number of the related action.

Question 7: Provide the case name of the related action.

Question 8: Provide the case number of the related action.

Section F: Award Justification

Use this section to explain the basis for your belief that you should be granted an award in connection with your submission of information to NHTSA. Specifically address how you believe you voluntarily provided NHTSA with original information that led to the successful resolution of a covered action. Provide any information that you think may be relevant in light of the criteria for determining the amount of an award set forth in 49 U.S.C. § 30172 and 49 C.F.R. Part 513.

49 U.S.C. § 30172(c) provides that in determining an award made under 49 U.S.C. § 30172(b), the Secretary shall take into consideration: (i) if appropriate, whether a whistleblower reported or attempted to report the information internally to an applicable motor vehicle manufacturer, part supplier, or dealership; (ii) the significance of the original information provided by the whistleblower to the successful resolution of the covered action; (iii) the degree of assistance provided by the whistleblower and any legal representative of the whistleblower in the covered action; and (iv) such additional factors as the Secretary considers relevant.

Section G: Claimant’s Declaration

This section must be completed and signed by the claimant.

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