3038-0082 Form TCR (Tip, Complaint or Referral)

UNIT
TED STATE
ES
COMMODIT
C
TY FUTUR
RES TRADIING COMM
MISSION
Washington, DC 200581

OMB APPR
ROVAL
OMB Numbber:
Expires:

3038-008
82
10/31/14
4

FO
ORM TCR
TIP
P, COMPLA
AINT OR R
REFERRAL
L
Please refer to the attached
a
Priva
acy Act Statem
ment, Submisssion Proceduures
and Instructiions for Comp
pleting Form TCR as needded to help yoou complete thhis form.

A. TELL US ABOUT
A
YO
OURSELF
COMPLAINA
ANT 1:
1. L
Last Name

Fiirst Name

M.I.

2. S
Street Address

Aparttment/Unit #

City

State/Provincee

ZIP/Postal Coode

Counntry

3. T
Telephone

Alt.
A Phone

E-mail Addreess

Preferrred Method of
Comm
munication

4. O
Occupation

Add Comp
plainant

Clickk here to add another
a
complaainant if this is a joint submission.

COMPLAINA
ANT 2:
1. L
Last Name

First Name

M.I.

2. Street Address

Aparttment/Unit #

City

State/Provincee

ZIP/Postal Coode

Country

3. T
Telephone

Alt.
A Phone

E-mail Address

Preferrred Method off
Comm
munication

4. O
Occupation

Please be advised
a
that purrsuant to 5 CFR
R 1320.5(b)(2)(i), you are not req
quired to respon
nd to this collec
ction of informa
ation
unless it dis
splays a curren
ntly valid OMB control
c
number.

B. Y
YOUR ATT
TORNEY’S
S INFORMA
ATION (If Applicable
A
– See Instru
uctions)
Clickk here if you are represented by an attorney
y, or if you are an attorney filiing on behalf oof your client.

Add Attorney

1. A
Attorney’s Nam
me

2. Firm Name

3. Street Address

City

State/Provincee

ZIP/Posstal Code

4. T
Telephone

Fax
F

E-mail A
Address

Country

C. TELL US WHO
W
YOU ARE COM
MPLAINING
G ABOUT
IND
DIVIDUAL//ENTITY 1:
1. T
Type:

Indiv
vidual

Enttity

If An Individu
ual, Specify Proofession. If Ann Entity, Specify Type.

2. N
Name

3. S
Street Address

Aparttment/Unit #

City

State/Provincee

4. T
Telephone

E-mail
E
Addresss

Z
ZIP/Postal Codde

Counntry

IInternet Addreess

Ad
dd Individuaal/Entity

Clickk here to add other
o
relevant in
ndividuals and
d/or entities.

IND
DIVIDUAL//ENTITY 2:
1. T
Type:

Indiv
vidual

Enttity

If
I An Individu
ual, Specify Proofession. If Ann Entity, Speciffy Type.

2. N
Name

3. Street Address

Aparttment/Unit #

City

State/Provincee

4. T
Telephone:

E-mail
E
Addresss:

Z
ZIP/Postal Codde

Counntry

IInternet Addreess:

D. TELL US ABOUT YOUR COMPLAINT
1. Occurrence Date (mm/dd/yyyy)

2. Nature of Complaint

3a. Type of Financial Product or Investment, if Applicable

3b. Name of Financial Product or Investment, if Applicable

4. State in detail all facts pertinent to the alleged violation. Explain why you believe the facts described constitute a violation of the
Commodity Exchange Act.

5. Describe all supporting materials in your possession and the availability and location of any additional supporting materials not in
your possession.

6. Describe how and from whom you obtained the information that supports your allegations. If any information was obtained from
an attorney or in a communication where an attorney was present, identify such information with as much particularity as possible.
In addition, if any information was obtained from a public source, identify the source with as much particularity as possible.

7. Identify with particularity any documents or other information in your submission that you believe could reasonably be expected
to reveal your identity and explain the basis for your belief that your identity would be revealed if the documents or information
were disclosed to a third party.

8a. Have you or your attorney had any prior communication(s) with the CFTC concerning this matter? YES

NO

8b. If the answer to 8a is “Yes,” name of CFTC staff member with whom you or your attorney communicated.

9a. Have you or your attorney provided the information to any other agency or organization, or has any other agency or organization
requested the information or related information from you? YES
NO
9b. If the answer to 9a is “Yes,” please provide details.

9c. Name and contact information for point of contact at other agency or organization, if known.

10a. Does this complaint relate to an entity of which you are or were an officer, director, counsel, employee, consultant or
contractor? YES
NO
10b. If the answer to question 10a is “Yes,” have you reported this violation to your supervisor, compliance office, whistleblower
hotline, ombudsman, or any other available mechanism at the entity for reporting violations? YES
NO
10c. If the answer to question 10b is “Yes,” please provide details.

10d. Date on which you took the action(s) described in question 10b (mm/dd/yyyy):

11a. Have you taken any other action regarding your complaint? YES
11b. If the answer to question 11a is “Yes,” please provide details.

12. Provide any additional information that you think may be relevant.

NO

E. WHISTLEBLOWER ELIGIBILITY REQUIREMENTS AND OTHER INFORMATION
1. Are you, or were you at the time that you acquired the original information that you are submitting to the Commission, a member,
officer or employee of the Department of Justice, the Commodity Futures Trading Commission, the Comptroller of the Currency, the
Board of Governors of the Federal Reserve System, the Federal Deposit Insurance Corporation, the Office of Thrift Supervision, the
National Credit Union Administration, the Securities and Exchange Commission, a registered entity, a registered futures association,
a self-regulatory organization, or any law enforcement organization?
YES

NO

2. Are you providing this information pursuant to a cooperation agreement with the Commodity Futures Trading Commission or
another agency or organization?
YES

NO

3. Are you providing this information before you (or anyone representing you) received any request, inquiry or demand that relates
to the subject matter of this submission (i) from the Commodity Futures Trading Commission, (ii) in connection with an
investigation, inspection or examination by any registered entity, registered futures association or self-regulatory organization, or
(iii) in connection with an investigation by the Congress, or any other federal or state authority?
YES

NO

4. Are you currently a subject or target of a criminal investigation, or have you been convicted of a criminal violation, in connection
with the information that you are submitting to the Commodity Futures Trading Commission?
YES

NO

5. Are you, or were you at the time you acquired the original information that you are submitting to the Commission, a member,
officer or employee of a foreign regulatory authority or law enforcement organization?
YES

NO

6. Did you acquire the information being provided to us from any person described in questions 1 through 5 above?
YES

NO

7. Use this space to provide additional details relating your responses to questions 1 through 6 above.

F. W
WHISTLEB
BLOWER’S
S DECLAR
RATION
I decclare under pen
nalty of perjury
y under the law
ws of the United
d States that thhe information contained hereein is true, corrrect and
compplete to the besst of my knowlledge, information and belieff. I fully underrstand that I maay be subject too prosecution aand ineligible
for a whistleblowerr award if, in my
m submission of information
n, my other deaalings with thee Commodity F
Futures Tradingg
Com
mmission, or my
y dealings with
h another autho
ority in connecction with a relaated action, I kknowingly and willfully makee any false,
fictittious or fraudu
ulent statementss or representattions, or use an
ny false writingg or document knowing that the writing or document
contaains any false, fictitious or frraudulent statem
ment or entry.
Printt Name

Date
Checck this box to agree
a
with the declaration abo
ove.

G. C
COUNSEL CERTIFIC
CATION
I certtify that I havee reviewed this form for comp
pleteness and accuracy
a
and thhat the informaation containedd herein is true,, correct and
compplete to the besst of my knowlledge, informattion and belief.
f. I further certtify that I have verified the iddentity of the w
whistleblower
s valid, unexpiired governmennt issued identtification (e.g.,
on w
whose behalf this form is being submitted by
y viewing the whistleblower’
w
driveer’s license, passport) and willl retain an orig
ginal, signed co
opy of this form
m, with Sectionn F signed by tthe whistleblow
wer, in my
recorrds. I further certify
c
that I haave obtained the whistlebloweer’s non-waivaable consent to provide the Coommodity Futuures Trading
Com
mmission with his
h or her origin
nal signed Form
m TCR upon request in the eevent that the C
Commodity Futtures Trading C
Commission
requeests it due to co
oncerns that th
he whistlebloweer may have kn
nowingly and w
willfully made false, fictitiouus or fraudulentt statements orr
repreesentations, or used any false writing or doccument knowin
ng that the writting or documeent contains any false, fictitioous or
frauddulent statemen
nt or entry; and
d that I consentt to be legally obligated
o
to doo so within seven (7) calendarr days of receivving such a
requeest from the Co
ommodity Futu
ures Trading Commission.
C
Printt Name of Atto
orney and Law Firm, if Appliicable

Date
Checck this box to agree
a
with the declaration abo
ove.

I havve read and und
derstand the Prrivacy Act Stattement for this form.

SU
UBMIT

Privacy Act Statement
This notice is given under the Privacy Act of 1974. The Privacy Act requires that the Commodity Futures
Trading Commission (CFTC or Commission) inform individuals of the following when asking for information. The
solicitation of this information is authorized under the Commodity Exchange Act, 7 U.S.C. § 1 et seq. This form may be
used by anyone wishing to provide the CFTC with information concerning a violation of the Commodity Exchange
Act or the Commission’s regulations. If an individual is submitting this information for the Commission’s
whistleblower award program pursuant to Section 23 of the Commodity Exchange Act, the information provided will
be used to enable the Commission to determine the individual’s eligibility for payment of an award. This information
will be used to investigate and prosecute violations of the Commodity Exchange Act and Commission regulations.
This information may be disclosed to Federal, state, local or foreign agencies or other authorities responsible for
investigating, prosecuting, enforcing or implementing laws, rules or regulations implicated by the information consistent
with the confidentiality requirements set forth therein, including pursuant to Section 23 of the Commodity Exchange Act
and Part 165 of the Commission’s regulations. The information will be maintained and additional disclosures may be
made in accordance with System of Records Notices CFTC-10, “Investigatory Records” (exempted), and CFTC-16,
“Enforcement Case Files.” Furnishing the information is voluntary. However, if an individual is providing
information for the whistleblower award program, not providing required information may result in the individual not
being eligible for award consideration.
Questions concerning this form may be directed to: Commodity Futures Trading Commission, Whistleblower
Office, Three Lafayette Centre, 1155 21st Street, N.W., Washington, DC 20581.
Submission Procedures
•

If you are submitting information for the Commission’s whistleblower award program, you must submit
your information using this Form TCR.

•

You may submit this form electronically, through the web portal found on the Commission’s website at
http://www.cftc.gov. You may also print this form and submit it by mail to: Commodity Futures Trading
Commission, Whistleblower Office, Three Lafayette Centre, 1151 21st Street, N.W., Washington, DC
20581, or by facsimile to (202) 418-5975.

•

You have the right to submit information anonymously. However, in order to receive a whistleblower
award, you will need to be identified to selected Commission staff for a final eligibility determination, and

in unusual circumstances, you may need to be identified publicly for trial. You should therefore provide
some means for the Commission’s staff to contact you, such as a telephone number or an e-mail address.
Instructions for Completing Form TCR
General
All references to “you” and “your” are intended to mean the whistleblower.
Section A: Tell Us About Yourself
Questions 1-4: Please provide the following information about yourself:
•

Last name, first name and middle initial;

•

Complete address, including city, state and zip code;

•

Telephone number and, if available, an alternate number where you can be reached;

•

Your e-mail address (to facilitate communications, we strongly encourage you to provide your email address, especially if you are filing anonymously);

•

Your preferred method of communication; and

•

Your occupation.

Section B: Your Attorney’s Information
Complete this section only if you are represented by an attorney in this matter.
Questions 1-4: Provide the following information about your attorney:
•

Attorney’s name;

•

Firm name;

•

Complete address, including city, state and zip code;

•

Telephone number and fax number; and

•

E-mail address.

Section C: Tell Us Who You Are Complaining About
Question 1:

Choose one of the following that best describes the individual’s profession or the type of entity to
which your complaint relates:
•

For Individuals: accountant, analyst, associated person, attorney, auditor, broker, commodity
trading advisor, commodity pool operator, compliance officer, employee, executing broker,

executive officer or director, financial planner, floor broker, floor trader, trader, unknown or
other (specify).
•

For Entities: bank, commodity trading advisor, commodity pool operator, commodity
pool, futures commission merchant, hedge fund, introducing broker, major swap
participant, retail foreign exchange dealer, swap dealer, unknown or other (specify).

Questions 2-4: For each individual and/or entity, provide the following information, if known:
•

Full name;

•

Complete address, including city, state and zip code;

•

Telephone number;

•

E-mail address; and

•

Internet address, if applicable.

Section D: Tell Us About Your Complaint
Question 1:

State the date (mm/dd/yyyy) that the alleged conduct began.

Question 2:

Choose the option that you believe best describes the nature of your complaint. If you are alleging
more than one violation, please list all that you believe may apply.
•

Theft/misappropriation;

•

Misrepresentation/omission (i.e., false/misleading marketing/sales literature; inaccurate,
misleading or non-disclosure by commodity pool operator, commodity trading advisor,
futures commission merchant, introducing broker, retail foreign exchange dealer, major
swap participant, swap dealer or their associated person(s); false/material
misstatements in any report or statement);

•

Ponzi/pyramid scheme;

•

Off-exchange foreign currency, commodity or precious metal fraud;

•

Registration violations (including unregistered commodity pool operator, commodity
trading advisor, futures commission merchant, introducing broker, retail foreign
exchange dealer, swap dealer or their associated person(s));

•

Trading (after hours trading, algorithmic trading, disruptive trading, front running, insider
trading, manipulation/attempted manipulation of commodity prices, market timing, inaccurate
quotes/pricing information, program trading, trading suspensions or volatility);

•

Fees/mark-ups/commissions (excessive, unnecessary or unearned administrative, commission
or sales fees; failure to disclose fees; insufficient notice of change in fees; excessive or otherwise
improper spreads or fills);

•

Sales and advisory practices (background information on past violations/integrity; breach of
fiduciary duty/responsibility; churning/excessive trading; cold calling; conflict of interest; abuse
of authority in discretionary trading; failure to respond to client, customer or participant;
guarantee against loss; promise to profit; high pressure sales techniques; instructions by client,
customer or participant not followed; investment objectives not followed; solicitation methods
(e.g., cold calling, seminars));

•

Customer accounts (unauthorized trading); identity theft affecting account; inaccurate valuation
of Net Asset Value; or

•

Other (analyst complaints, market maker activities, employer/employee disputes or other
(specify)).

Question 3a:

Choose from the following the option that you believe best describes the type of financial product
or investment at issue, if applicable:
y Commodity futures;
y Options on commodity futures;
y Commodity options;
y Foreign currency transactions;
y Swaps; or
y Other (specify).

Question 3b:

Provide the name of the financial product or investment, if applicable.

Question 4:

State in detail all the facts pertinent to the alleged violation. Explain why you believe the facts
described constitute a violation of the Commodity Exchange Act.

Question 5:

Describe all supporting materials in your possession, custody or control, and the availability and
location of additional supporting materials not in your possession, custody or control.

Question 6:

Describe how you obtained the information that supports your allegations. If any information was
obtained from an attorney or in a communication where an attorney was present, identify such
information with as much particularity as possible. In addition, if any information was obtained
from a public source, identify the source with as much particularity as possible.

Question 7:

You may use this space to identify any documents or other information in your submission on this
Form TCR that you believe could reasonably be expected to reveal your identity. Explain the
basis for your belief that your identity would be revealed if the documents or information were
disclosed to a third party.

Question 8a:

State whether you or your attorney have had any prior communications with the Commission
concerning this matter.

Question 8b:

If the answer to question 8a is yes, provide the name of the Commission staff member with whom
the you or your attorney communicated.

Question 9a:

Indicate whether you or your attorney have provided the information you are providing to the
Commission to any other agency or organization.

Question 9b:

If the answer to question 9a is yes, provide details.

Question 9c:

Provide the name and contact information of the point of contact at the other agency or
organization, if known.

Question 10a:

Indicate whether your complaint relates to an entity of which you are, or were in the past, an
officer, director, counsel, employee, consultant or contractor.

Question 10b:

If the answer to question 10a is yes, state whether you have reported this violation to your
supervisor, compliance office, whistleblower hotline, ombudsman, or any other available
mechanism at the entity for reporting violations.

Question 10c:

If the answer to question 10b is yes, provide details.

Question 10d:

Provide the date on which you took the actions described in questions 10a and 10b.

Question 11a:

Indicate whether you have taken any other action regarding your complaint, including whether you
complained to the Commission, another regulator, a law enforcement agency, or any other

agency or organization; initiated legal action, mediation or arbitration, or initiated any other
action.
Question 11b:

If you answered yes to question 11a, provide details, including the date on which you took the
action(s) described, the name of the person or entity to whom you directed any report or
complaint, and contact information for the person or entity, if known, and the complete case name,
case number, and forum of any legal action you have taken.

Question 12:

Provide any additional information you think may be relevant.

Section E: Whistleblower Eligibility Requirements And Other Information
Question 1:

State whether you are currently, or were at the time that you acquired the original information that
you are submitting to the Commission, a member, officer or employee of the Department of
Justice, the Commodity Futures Trading Commission, the Comptroller of the Currency, the Board
of Governors of the Federal Reserve System, the Federal Deposit Insurance Corporation, the
Office Thrift Supervision, National Credit Union Administration, the Securities and Exchange
Commission, a registered entity, a registered futures association, a self-regulatory organization, or
any law enforcement organization.

Question 2:

State whether you are providing the information pursuant to a cooperation agreement with the
Commission or with another agency or organization.

Question 3:

State whether you are providing this information before you (or anyone representing you) received
any request, inquiry or demand that relates to the subject matter of this submission (i) from the
Commission, (ii) in connection with an investigation, inspection or examination by any registered
entity, registered futures association or self-regulatory organization, or (iii) in connection with an
investigation by the Congress, or any other federal or state authority.

Question 4:

State whether you are currently a subject or target of a criminal investigation, or whether you have
been convicted of a criminal violation, in connection with the information you are submitting to
the Commission.

Question 5:

State whether you are currently, or were at the time that you acquired the original information that
you are submitting to the Commission, a member, officer or employee of a foreign regulatory
authority or law enforcement organization.

Question 6:

State whether you acquired the information you are providing to the Commission from any
individual described in Questions 1 through 5 of this Section.

Question 7:

Use this space to provide additional details relating to your responses to questions 1 through 6 of
this Section.

SECTION F: Whistleblower’s Declaration.
You must sign this Declaration if you are submitting this information pursuant to the Commodity Futures
Trading Commission whistleblower program and wish to be considered for an award. If you are submitting your
information using the electronic version of Form TCR through the Commission’s web portal, you must check the
box to agree with the declaration. If you are submitting your information anonymously, you must still sign this
Declaration or check the box as appropriate, and you must provide your attorney with the original of this signed
form, or maintain a copy for your own records. If you are not submitting your information pursuant to the
Commodity Futures Trading Commission whistleblower program, you do not need to sign this Declaration or check
the box.
SECTION G: Counsel Certification
If you are submitting this information pursuant to the Commodity Futures Trading Commission
whistleblower program and you are doing so anonymously through an attorney, your attorney must sign the Counsel
Certification section. If your attorney is submitting your information using the electronic version of Form TCR
through the Commission’s web portal, he/she must check the box to agree with the certification. If you are
represented in this matter but you are not submitting your information pursuant to the Commodity Futures Trading
Commission whistleblower program, your attorney does not need to sign this Certification or check the box.