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.

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

Complainant

B. YOUR ATTORNEY'S INFORMATION (IF APPLICABLE – SEE INSTRUCTIONS)

C. TELL US WHO YOU ARE COMPLAINING ABOUT

INDIVIDUAL/ENTITY

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1000 characters remaining.

D. TELL US ABOUT YOUR COMPLAINT

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4000 characters remaining.

E. WHISTLEBLOWER PROGRAM

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F. WHISTLEBLOWER ELIGIBILITY REQUIREMENTS AND OTHER INFORMATION

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FILE UPLOADS

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G. PRIVACY NOTICE AND WHISTLEBLOWER’S DECLARATION

PRIVACY ACT STATEMENT

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

  1. PURPOSE


    The information provided will help the Commodity Futures Trading Commission (“CFTC” or “Commission”) identify, investigate, and prosecute violations of the Commodity Exchange Act (“CEA”) or the regulations promulgated thereunder. If an individual wishes to be considered for the Commission’s whistleblower award program, the information provided will also be used by the Commission to determine the individual’s eligibility for payment of an award.

  2. AUTHORITY


    The Commission’s collection of this information from persons seeking to participate in the Commission’s whistleblower program is authorized under 7 U.S.C. § 26 and 17 C.F.R. § 165.

  3. ROUTINE USES


    The Commission may disclose this information when required 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 or to protect the public, the Commission may disclose this 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.

    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, exercised in accordance with the confidentiality provisions in the CEA and 17 C.F.R. § 165.4. A complete set of blanket routine uses for Commission SORNs is published in the Federal Register at 76 FR 5974 (Feb. 2, 2011).

  4. EFFECT OF NOT PROVIDING INFORMATION


    Furnishing information on or through this form is voluntary and may be done anonymously. However, failure to provide 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.

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.

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.

SUBMISSION