NOTE: SOME CONTENTS OF THIS FORM REDACTED DUE TO PRIVACY CONCERNS
(SEE SUB-PAGES FOR ATTACHMENTS)
(Rev. December 2007)
Department of the Treasury -Internal Revenue Service
Application for Award for
OMB No. 1545-0409
Date Claim Received:
Claim No. (completed by IRS)
1. Bobby N. Harmon 2. Claimant's Date of Birth
Month Day Year
3. Claimant's SSN or ITIN
4. Name of spouse(if applicable) 5. Spouse's Date of Birth
Month Day Year
6. Spouse's SSN or ITIN
7. Address of claimant, including zip code, and telephone number
8. Name & Title of IRS employee to whom violation was reported:
Janet Hughes and Carolyn Woods, Mgr.
9. Date violation reported:
10. Name of taxpayer (include aliases) and any related taxpayers who committed the violation:
Kamehameha Schools/Bishop Estate, Pauahi Holdings, Inc., P&C Insurance Co.
11. Taxpayer Identification Number(s) (e.g.,SSN, ITIN, or EIN):
12. Taxpayer's address, including zip code:
567 So. King St., Ste200, Honolulu, HI 96813 13. Taxpayer's date of birth or approximate age:
14. State the facts pertinent to the alleged violation. (Attach a detailed explanation and all supporting information in your possession
and describe the availability and location of any additional supporting information not in your possession.) Explain why you believe the
act described constitutes a violation of the tax laws:
This is a complex case involving tax fraud, bribes, bid-rigging, kick-backs, money-laundering, racketeering, unfair claims settlement practices, undisclosed conflicts-of-interest, and other illegal activities involving Kamehameha Schools/Bishop Estate, Marsh & McLennan, Aon, Chubb Group, Ace Ltd., Zurich Financial and others. Attached are a few of the hundreds of supporting documents which are available on-line.
15. Describe how you learned about and/or obtained the information that supports this claim and describe your present or former
relationship to the alleged noncompliant taxpayer(s). (Attach sheet if needed.)
I was employed by KSBE, a tax-exempt charitable rust, from Nov. 1988, and the president of P&C Insurance Co., a for-profit subsidiary of Pauahi Holdings Corp. from Oct. 1994. I was terminated from poth positions on Nov 20, 1996, due to my refusal to obey directives from my superiors to commit tax fraud and other illegal acts. See attached documents for further details. You will find related documents on-line at:
16. Describe the amount owed by the taxpayer(s). Please provide a summary of the information you have that supports your claim as
to the amount owed. (Attach sheet if needed.)
Total amount is unknown to me, but it is estimated to be over $100 million.
Declaration under Penalty of Perjury
I declare under penalty of perjury that I have examined this application, my accompanying statement, and supporting documentation
and aver that such application is true, correct, and complete, to the best of my knowledge.
17. Signature of Claimant:
(s) Bobby N. Harmon
18. Date 3/21/11
MAIL THE COMPLETED FORM TO THE ADDRESS SHOWN ON THE BACK
Form 211 (Rev. 12-2007) Catalog Number 16571S publish.no.irs.gov Department of the Treasury-Internal Revenue Service
On December 20, 2006, Congress made provision for the establishment of a Whistleblower Office within the IRS. This office has
responsibility for the administration of the informant award program under section 7623 of the Internal Revenue Code. Section 7623
authorizes the payment of awards from the proceeds of amounts the Government collects by reason of the information provided by
the claimant. Payment of awards under 7623(a) is made at the discretion of the IRS. To be eligible for an award under Section
7623(b), the amount in dispute (including tax, penalties, interest, additions to tax, and additional amounts) must exceed
$2,000,000.00; if the taxpayer is an individual, the individual's gross income must exceed $200,000.00 for any taxable year at issue.
Send completed form along with any supporting information to:
Internal Revenue Service
1111 Constitution Ave., NW
Washington, DC 20224
Send the completed Form 211 to the above Washington address of the Whistleblower Office. Do NOT send the Form 211 to the Tax Forms Coordinating Committee....