Reparations Complaint Form

Instructions

If the space provided on this form is not sufficient, attach your own supplementary sheets containing the required information.

Notice: Reporting burden for this collection of information is estimated to average 1.5 hours per response. Send comments regarding this burden estimate or another aspect of this collection of information to Agency Clearance Officer, Office of General Counsel, Commodity Futures Trading Commission, Three Lafayette Centre, 1155 21st Street, NW, Washington, DC 20581; or to the OMB Office of Information and Regulatory Affairs, Attn: CFTC Desk Officer, Washington, DC 20503. Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subjected to a penalty for failure to comply with, a collection of information subject to the requirements of the Paperwork Reduction Act, unless that collection of information displays a currently valid OMB Control Number. For this collection, OMB has issued control number 3038-0115.

PLEASE NOTE: To help ensure your privacy and security, unless you affirmatively extend your session when prompted, the online form will timeout after 65 minutes, and ALL DATA WILL BE LOST. You will then need to re-access the form to re-enter information in all the fields.

Fields marked with a red exclamation () are required

SECTION A. COMPLAINANT INFORMATION (TELL US ABOUT YOURSELF)

Complainant 1

Type

Person

Entity

Entity Name

First Name

Middle Initial

Last Name

Street Address

City

State/Province

Zip/Postal Code

Country

Home Phone

Work Phone

Fax Phone

Email Address

SECTION B. COMPLAINANT’S ATTORNEY’S INFORMATION (IF APPLICABLE)

Are you represented by an attorney in connection with your submission?

Yes

No

If Yes is selected, Attorney is required.

SECTION C. RESPONDENT’S INFORMATION

1. Registered persons and/or firms you think violated the Commodity Exchange Act

You can verify that the person(s) and/or firm(s) named in the complaint were registered with the CFTC at the time of the alleged offense by calling (202) 418-5506 or emailing proceedings@cftc.gov for registration information.

PLEASE ENSURE NAMED RESPONDENT(S) WERE REGISTERED WITH THE CFTC AT THE TIME OF THE ALLEGED OFFENSE PRIOR TO SUBMITTING THE FORM AND PAYING THE NONREFUNDABLE REQUIRED FILING FEE!

Respondent 1

Type

Person

Entity

Entity Name

First Name

Middle Initial

Last Name

Street Address

City

State/Province

Zip/Postal Code

Country

Work Phone

Fax Phone

Email Address

Was this individual/firm registered with the CFTC at the time of the alleged violation?

Yes

No

2. If known, cite the specific portions of the Act, rules or regulations violated:

1000 characters remaining.

3. Description of complaint. Describe in detail, giving names, dates and the facts which will show how the Commodity Exchange Act was violated and how you were injured by that violation. You must set forth this information on supplementary sheets which you must attach to this complaint form.

3000 characters remaining.

4. Amount of damages claimed. You must include an explanation of how you calculated the damages you have claimed.

1000 characters remaining.

5. Have you brought another action based on the same set of facts in an arbitration forum or civil court?

Yes

No

If yes, has the case been decided?

Yes

No

6. To your knowledge, are any of the respondents you named the subject of an ongoing receivership or bankruptcy proceedings?

Yes

No

SECTION D: ATTACHMENTS AND DOCUMENTATION SUPPORTING YOUR COMPLAINT

Click the ‘+ Add Files’ button to select the file(s) to upload

To upload your document(s) please use the following guidance:

Do not password protect or encrypt files; they cannot be checked for malware and viruses.
You may upload up to 10 separate files.
Files are limited to a size of 10 MB.
Valid file formats include: doc, docx, dot, xls, xlsx, jpg, jpeg, pdf, bmp, txt, ppt, pptx, odt, ods, odp, zip, zipx.
File names cannot contain the following special characters: * ? # % ~ & : { } | ' < > " /

Add Files

SECTION E: PRIVACY ACT NOTICE

The Commission’s authority for soliciting this information is granted in 7 U.S.C. § 18 and Part 12 of the Commission’s regulations. The information on this form is primarily used by the Commission’s Office of Proceedings to determine if the complaint is sufficiently complete for further processing and to initiate and move forward a reparations proceeding. Information contained in the form and complaint may be used by the Commission during any and all phases of a reparations case including, but not limited to, discovery, litigation, appeals and in written opinions and orders. Information provided may be made public in accordance with provisions of the CEA and other applicable laws. Under “open government” principles and rules, the Commission generally posts final reparations and appellate decisions to its public website, which may result in the decisions being captured and displayed through Internet search engines. The information may also be disclosed to other government agencies or CFTC divisions, for example the Division of Enforcement, to meet their responsibilities assigned to them by law. It will be maintained and additional disclosures may be made in accordance with CFTC System of Records Notices, e.g., CFTC-3, Docket Files for Reparations and Administrative Adjudication and CFTC-29, Reparations Cases Closed in the Complaints Section, available on http://www.cftc.gov/Transparency/PrivacyOffice/SORN/index.htm. If you do not provide the requested information, the Office of Proceedings may not be able to process your complaint.

SECTION F: Verification

I hereby swear or affirm (under penalty of law) that the facts set forth in this complaint are known to be true or, based on my best information, are believed to be true. To the extent that any facts are believed, instead of known, to be true, the information upon which I formed that belief is set forth as follows (attach detailed, specific information on a supplementary sheet):

Complainant’s Signature 1

Name

Date

SECTION G: PAYMENT

The filing fee can be paid electronically via www.pay.gov. Select “reparations filing fee” from the dropdown and include the filing fee amount and type of decisional proceedings: (1) $50 Voluntary Decisional Procedure; (2) $125 Summary Decisional Procedure; or (3) $250 Formal Decisional Procedure in the narrative section. Please attach the payment confirmation receipt before submitting the complaint or email it to the proceedings@cftc.gov mailbox. Confirmation of payment must be received before complaint is accepted and filed. NOTICE: FILING FEES, ONCE PAID TO THE COMMODITY FUTURES TRADING COMMISSION, ARE NOT REFUNDABLE.