Form WB-APP

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

Please refer to the attached Privacy Act Statement, 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: Commodity Future Trading Commission, Whistleblower Office, Three Lafayette Centre, 1155 21st Street, NW, Washington, DC 20581. Fax Number (202) 418-5975.

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Fields marked with a red exclamation () are required

A. TELL US ABOUT YOURSELF (Required for All Submissions)

B. YOUR ATTORNEY’S INFORMATION (If Applicable - See Instructions)

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C. TELL US ABOUT YOUR TIP OR COMPLAINT

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D. NOTICE OF COVERED ACTION

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E. CLAIMS PERTAINING TO RELATED ACTIONS

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F. ELIGIBILITY REQUIREMENTS AND OTHER INFORMATION

G. ENTITLEMENT TO AWARD

SUPPORTING DOCUMENTS

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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.

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.

Check this box to agree with the declaration above.

AUTHENTICATION AND CONSENT

SUBMISSION