2. Whistleblower Complaint Form
   (Type or Print clearly)
4. Return to:
   Timothy S. Esquinaldo
   Internal Compliance Auditor
   1100 Kennedy Drive
   Key West, Fl. 33040
   Telephone: (954) 357-7896
   E-mail: tesquinaldo@fkaa.com
6. Person (Name of Person) Filing Whistleblower Report:
8. First Name
9. Last Name
10. Date:
    Date:
11. Division:
13. Work Phone
14. Address
16. Home Phone
17. Work Location
18. Best time to call
    Best time to call Start Time

    —

    Best time to call End Time
20. Independent Contractor or Private Citizen
24. Complaint Filed Against:
26. Name(s)
27. Their Supervisor(s) if known
29. Position/Title
30. Department
31. Division
32. Location
36. Type of Improper Activity (Please check)

    1. Violation or suspected violation of federal, state or local law or regulation, committed by a FKAA employee or agent, or independent contractor, which poses a substantial and specific danger.
    2. Act or suspected act of mismanagement, malfeasance (performance of a wrongful act), or misfeasance (misuse of power or authority)committed by an employee, agent, or independent contractor of the FKAA.
    3. Act or suspected act of waste of public funds by an employee, agent, or independent contractor of the FKAA.
    4. Act or suspected act of neglect of duty committed by an employee, agent, or independent contractor of the FKAA.
38. What is the allegation of improper activity?
    Please describe in detail.*
40. When did the event(s) take place?
    Please indicate date, time, and frequency.*
42. Where did the event(s) occur?*
44. Are there other witnesses?

    1. Yes
    2. No
46. If so, what are their names, positions, and divisions?*
48. Is there evidence that can be examined or documentation which can be reviewed?*
    If yes, describe the evidence and where it can be found, if known.
50. How do you know about the improper action? Did you see it occur? Did you see documentation indicating it occurred? Did you hear about it from someone?*
52. Were there any witnesses to the improper act? If so, identify by name, home/work address, home/work telephone number, or where they can be reached during the day.
54. What specific law or state regulation has been violated, if you know?
56. Have you filed a complaint with this Office previously?

    1. Yes
    2. No
57. Is this complaint now pending with any other Agency?

    1. Yes
    2. No
59. If yes, please give the name(s) and address(es) of the Agency(ies)
61. Signature
62. Date
    Date
64. *If additional space is needed, please email tesquinaldo@fkaa.com.
Leave This Blank:


68. 1. Receive an email copy of this form.
69. Email address

    This field is not part of the form submission.

70. Submit

* indicates a required field