Form WB-APP

Instructions

APPLICATION FOR AWARD FOR ORIGINAL INFORMATION PROVIDED
PURSUANT TO SECTION 23 OF THE COMMODITY EXCHANGE ACT

Please refer to the attached Submission Procedures, and Completion Instructions as needed to help you complete this form. Or, to submit the form by mail or facsimile, print out the Form WB-APP and mail or fax the completed form to: CFTC, Whistleblower Office, 1155 21st Street, NW, Washington, DC 20581. Fax Number (202) 418-5975.

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. If you cannot enter and submit your information in the time allotted, please consider submitting substantive information as an attachment and referencing the attachment when completing the form.

Fields marked with a red exclamation () are required

A. TELL US ABOUT YOURSELF (REQUIRED FOR ALL SUBMISSIONS)

If you would like to submit anonymously please enter Anonymous in the last name field.

1. Last Name

First Name

M.I.

SSN Last Four Digits

2. Street Address

Apartment/Unit #

City

Country

Zip/Postal Code

3. Telephone

Alt. Phone

Email Address

B. YOUR ATTORNEY’S INFORMATION (IF APPLICABLE - SEE INSTRUCTIONS)

C. TELL US ABOUT YOUR TIP OR COMPLAINT

1a. How did you submit original information to the CFTC?

Website

Mail

Fax

Other

1b. Date you submitted the information

2a. Did you file a CFTC Form TCR?

Yes

No

2b. Form TCR Number

2c. Date you filed your Form TCR

3. Name(s) of the individual(s) and/or entity(s) to which your tip or complaint relates. File attachments (below Section G) may be used in place of, or in addition to, the narrative text.

4000 characters remaining.

D. NOTICE OF COVERED ACTION

1. Date of relevant Notice of Covered Action

2. Notice Number

3a. Case Name

3b. Case Number

E. CLAIMS PERTAINING TO RELATED ACTIONS

1. Name of other agency or organization to which you provided your information. File attachments (below Section G) may be used in place of, or in addition to, the narrative text.

4000 characters remaining.

2. Name and contact information for point of contact at the agency or organization, if known. File attachments (below Section G) may be used in place of, or in addition to, the narrative text.

4000 characters remaining.

3a. Date you provided the information

3b. Date of action by the agency or organization

4a. Case Name

4b. Case Number

F. ELIGIBILITY REQUIREMENTS AND OTHER INFORMATION

G. ENTITLEMENT TO AWARD

Explain the basis for your belief that you are entitled to an award in connection with your submission of information to the CFTC, or to another agency or organization in a related action. Provide any additional information that you think may be relevant in light of the criteria for determining the amount of an award set forth in Section 23 of the Commodity Exchange Act and Part 165 of the CFTC’s regulations. Include any supporting documents in your possession or control. File attachments (below Section G) may be used in place of, or in addition to, the narrative text.

16000 characters remaining.

SUPPORTING DOCUMENTS

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, and odp.
File names cannot contain the following special characters: * ? # % ~ & : { } | " < > " /

Add Files

H. CLAIMANT’S DECLARATION

Complete at least one of the following two sections (H or I).

I declare under penalty of perjury under the laws of the United States that the information contained herein is true, correct and complete 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, my other dealings with the Commodity Futures Trading Commission, or my dealings with another agency or organization 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.

Name

Date

I agree. (Check this box to agree with the declaration above.)

I. COUNSEL CERTIFICATION

I certify that I have reviewed this form for completeness and accuracy and that the information contained herein is true, correct and complete to the best of my knowledge, information and belief. I further certify that I have verified the identity of the whistleblower on whose behalf this form is being submitted by viewing the whistleblower's valid, unexpired government issued identification (e.g., driver's license, passport) and will retain an original, signed copy of this form, with Section F signed by the whistleblower, in my records. I further certify that I have obtained the whistleblower's non-waivable consent to provide the Commodity Futures Trading Commission with his or her original signed Form TCR upon request in the event that the Commodity Futures Trading Commission requests it due to concerns that the whistleblower may have knowingly and willfully made false, fictitious, or fraudulent statements or representations, or used any false writing or document knowing that the writing or document contains any false fictitious or fraudulent statement or entry, and that I consent to be legally obligated to do so within seven (7) calendar days of receiving such a request from the Commodity Futures Trading Commission.

Attorney Name

Law Firm Name

Date

I agree. (Check this box to agree with the declaration above.)

PRIVACY ACT

PRIVACY ACT STATEMENT

The collection, maintenance, and disclosure of this information is governed by the Privacy Act of 1974 (5 U.S.C. § 552a).

PURPOSE
The information provided will enable the Commodity Futures Trading Commission (“CFTC” or “Commission”) to determine the eligibility of the whistleblower award claimant and to investigate and prosecute violations of the Commodity Exchange Act or the regulations promulgated thereunder.
AUTHORITY
The Commission’s collection of this information from persons seeking to participate in the Commission’s whistleblower award program is authorized under 7 U.S.C. § 26 and 17 C.F.R. § 165. The CFTC requests the last four digits of the claimant’s Social Security number for use as an individual identifier to administer and manage the whistleblower award program. Executive Order 9397 (November 22, 1943) allows federal agencies to use the Social Security number as an individual identifier.
ROUTINE USES
This information may be disclosed to federal, state, local or foreign agencies or other authorities responsible for investigating, prosecuting, enforcing or implementing applicable laws, rules or regulations consistent with the confidentiality requirements set forth in 7 U.S.C. § 26 and 17 C.F.R. § 165. The information will be maintained and any disclosures will be made in accordance with the Commission’s Privacy Act system of records notices (SORNs) CFTC-49, Whistleblower Records available at 77 FR 41378, CFTC-10, Investigatory Records available at 76 FR 5973, and CFTC-16, Enforcement Case Files available at 76 FR 5973. A complete set of blanket routine uses for Commission SORNs is published in the Federal Register at 76 FR 5974 (Feb. 2, 2011).
EFFECT OF NOT PROVIDING INFORMATION
Providing this information is voluntary. However, not providing identifying information may result in ineligibility for consideration under the Commission’s whistleblower award program. Award candidates must be identified to a limited number of Commission staff for a final eligibility determination, and in unusual circumstances may need to be identified publicly for trial.