Form TCR

Instructions

TIP, COMPLAINT OR REFERRAL

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 TCR and mail or fax the completed form to: CFTC, Whistleblower Office, 1155 21st Street, NW, Washington, DC 20581. Fax Number (202) 418-5975.

After 65 minutes of inactivity, your form will timeout and all data will be lost. You will then need to re-access the form and enter your data again.

Fields marked with a red exclamation () are required

A. TELL US ABOUT YOURSELF

Complainant

1. Last Name

2. First Name

3. M.I.

4. Street Address

5. Apartment/Unit #

6. City

7. State/Province

8. ZIP/Postal Code

9. Country

10. Telephone

11. Alt. Telephone

12. E-mail Address

13. Preferred Method of Communication

14. Occupation

B. YOUR ATTORNEY'S INFORMATION (If Applicable – See Instructions)

If you are represented by an attorney, or if you are an attorney filing on behalf of your client.

1. Attorney's Name

2. Firm Name

3. Street Address

4. City

5. State/Province

6. ZIP/Postal Code

7. Country

8. Telephone

9. Fax

10. E-mail Address

C. TELL US WHO YOU ARE COMPLAINING ABOUT

Individual/Entity

1. Type

IndividualEntity

2. If an individual, specify profession. If an entity, specify type.

3. Name

4. Street Address

5. Apartment/Unit #

6. City

7. State/Province

8. ZIP/Postal Code

9. Country

10. Telephone

11. E-mail Address

12. Internet Address

13. If you are complaining about a firm or individual that has custody or control of your investments, have you had difficulty contacting that entity or individual?

YesNoUnknown

14. Are you or were you associated with the individual or firm when the alleged conduct occurred?

YesNoUnknown

If yes, describe how you are, or were, associated with the individual or firm you are complaining about.

15. What was the initial form of contact between you and the person against whom you are filing this complaint?

If other, please describe:

D. TELL US ABOUT YOUR COMPLAINT

1. Occurrence Date (mm/dd/yyyy):

Open the calendar popup.

2. Is the conduct on-going?

YesNoDon't Know

3. Please select the option(s) that best describes your complaint.

Fraudulent representations that persuaded you to trade futures, options, swaps, forex, or leveraged transactions

Some type of cheating or fraud that occurred after you had deposited funds to trade futures, options, swaps, forex, retail commodity, or leveraged transactions (for example, if someone used the funds you deposited to pay off someone else or you have asked for the return of your funds and have been refused).

Someone or some firm that should be registered under the Commodity Exchange Act, but is not.

Disruptive or manipulative trading activity in the futures, options or swaps markets.

The trading of futures options, or swaps based upon confidential information by someone not allowed to use such information.

Complaint does not fit into any of the above-described categories.

Please describe.

4. Select the type of product/instrument:

A futures contract, including a single stock futures contract, a narrow based or broad based security future contract.

An option on a futures contract, an option on a commodity, BUT NOT an option on a security or a basket of securities.

A swap, including a mixed swap BUT NOT a swap based on a single security or based on a narrow (i.e., nine or less) index of securities.

A cash (or physical) contract traded in interstate commerce.

A foreign currency transaction.

Are you an individual that trades or invests more than $10,000,000 on a discretionary basis?

YesNo

Are you an individual that trades or invests more than $5,000,000 and enters into the foreign currency agreement to manage the risk associated with some other asset or liability?

YesNo

A commodity transaction entered into or offered on a leveraged or margined basis, or financed by the offeror, the counterparty, or someone acting in concert with the offeror or counterparty.

Are you an individual that trades or invests more than $10,000,000 on a discretionary basis?

YesNo

Are you an individual that trades or invests more than $5,000,000 and enters into the foreign currency agreement to manage the risk associated with some other asset or liability?

YesNo

Other

If other, please describe:

5. If applicable, what is the name of product/investment?

6. Have you suffered a monetary loss?

YesNo

If yes, describe how much.

7. Has the individual or firm who engaged in the conduct acknowledged their fault?

YesNo

8. Have you or anyone else taken any action against the firm or person who engaged in the alleged conduct?

YesNo

Select the appropriate category:

Prior complaint to the CFTC.

Complaint to another regulator.

A state or federal criminal law enforcement entity.

A legal action filed against the person or firm in a court of law.

Additional comments based on above selection (e.g., Who, When, Contact, To whom made, Case Number, Court).

9. 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.

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

E. WHISTLEBLOWER PROGRAM

1. 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.

2. 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.

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

YesNo

If Yes, please identify the CFTC staff member(s) with whom you or your attorney communicated.

4. 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?

YesNo

If Yes, please provide details.

If Yes, please provide the name and contact information of the point of contact at the other agency or organization, if known.

5. Does this complaint relate to an entity of which you are or were an officer, director, counsel, employee, consultant or contractor?

YesNo

If Yes, have you reported this violation to your supervisor, compliance office, whistle blower hotline, ombudsman, or any other available mechanism at the entity for reporting violations?

YesNo

If Yes, please provide details including the date you took the action(s).

6. Have you taken any other action regarding your complaint?

YesNo

If Yes, please provide details.

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

F. WHISTLEBLOWER ELIGIBILITY REQUIREMENTS AND OTHER INFORMATION

1. Are you currently, or were you at the time that you acquired the original information that you are submitting to the CFTC, a member, officer or employee of: the CFTC; the Board of Governors of the Federal Reserve System; the Office of the Comptroller of the Currency; the Board of Directors of the Federal Deposit Insurance Corporation; the Director of the Office of Thrift Supervision; the National Credit Union Administration Board; the Securities and Exchange Commission; the Department of Justice; a registered entity; a registered futures association; a self-regulatory organization; a law enforcement organization (as defined in 3(a) of the Securities Exchange Act of 1934 (15 U.S.C. 78 c(a)); or a foreign regulatory authority or law enforcement organization?

YesNo

2. Are you providing this information pursuant to a cooperation agreement with the CFTC or another agency or organization?

YesNo

3. Before you provided this information, did you (or anyone representing you) receive any request, inquiry or demand that relates to the subject matter of this submission (i) from the CFTC, (ii) in connection with an investigation, inspection or examination by any registered entity, registered futures association or self-regulatory organization (as defined in 3(a) of the Securities Exchange Act of 1934 (15 U.S.C. 78 c(a)), or (iii) in connection with an investigation by the Congress, or any other federal or state authority?

YesNo

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 CFTC?

YesNo

5. Did you acquire the information being provided to the CFTC from any person described in Questions 1 through 4 above?

YesNo

6. If you answered Yes to any Questions 1 through 5 above, please provide details.

FILE UPLOADS

The CFTC Portal is encrypted throughout transmission and processing. It is not necessary to password protect or encrypt uploaded files. These files will be rejected since they cannot be automatically checked for malware and viruses.

You may upload up to 10 separate files.
Files are limited to a size of 10 MB each.
Acceptable Formats ( .doc,.docx,.dot,.xls,.xlsx,.jpg,.jpeg,.pdf,.bmp,.txt,.ppt,.pptx,.odt,.ods,.odp,.zip,.zipx).
A file name cannot contain the following special characters: * ? # % ~ & : { } | ' < > " \ /
If additional attachments are needed for your submission please submit the form as many times as necessary.
Depending on the size of your submission, the transaction can take as long as 4 minutes.

G. PRIVACY NOTICE AND WHISTLEBLOWER’S DECLARATION

PRIVACY NOTICE

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.

WHISTLEBLOWER’S DECLARATION

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.

Name

Date

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

H. 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.

Name of Attorney and Law Firm, if Applicable.

Date

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

AUTHENTICATION AND CONSENT

I agree to the collection, processing, use and disclosure of my personal information as stated in the Privacy Policy for www.cftc.gov.

SUBMISSION

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