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 CFTC's
regulations. This form and related information will be processed in the United States of America, the location of the CFTC. If an
individual is submitting this information for the CFTC's whistleblower award program pursuant to Section 23 of the Commodity
Exchange Act, the information provided will be used to enable the CFTC 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 the CFTC's
regulations. The CFTC may disclose this information when required to be disclosed to a defendant or respondent in connection with
a public proceeding instituted by the Commission. In addition, if the Commission determines such disclosure is necessary or
appropriate to accomplish the purposes of the CEA and to protect customers, the Commission may provide such information to the
Department of Justice; an appropriate department or agency of the Federal Government; a state attorney general; any appropriate
department or agency of a state; a registered entity, registered futures association, or self-regulatory organization (as defined in
Section 3(a) of the Securities Exchange Act of 1934 (15 U.S.C. 78c(a)); or a foreign futures authority. Those entities are subject to
the same confidentiality requirements as the Commission. The Commission also may disclose such information in accordance with
Privacy Act of 1974 System of Records Notices CFTC-49, "Whistleblower Records" (exempted), CFTC-10, "Investigatory
Records" (exempted), and CFTC-16, "Enforcement Case Files," (available on the CFTC Privacy Program web page,www.cftc.gov/Transparency/PrivacyOffice
) exercised in accordance with the confidentiality provisions in the CEA and 17 CFR
165.4. Furnishing information on or through this form is voluntary. However, if an individual is providing information for the
whistle blower award program, not providing required information may result in the individual not being eligible for award
consideration. Also, you may choose to submit this form anonymously, but in order to receive a whistleblower award, you would
need to be identified to select CFTC staff for a final eligibility determination, and in unusual circumstances, you may need to be
identified publicly for trial. [See instructions for further information.] By signing this Declaration, I am agreeing to the collection,
processing, use, and disclosure of my personally identifiable information as stated herein.
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 whistle blower award if, in my submission of information, my other dealings with the Commodity Futures Trading
Commission, or my dealings with another authority 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.