Form WB-1 Form TCR

UNITED STATES

SECURITIES AND EXCHANGE COMMISSION

Washington, D.C. 20549

FORM TCR

TIP, COMPLAINT OR REFERRAL

A.

INFORMATION ABOUT YOU

1. Last Name

First

M.I.
Apartment/
Unit #

2. Street Address

City

State/
Province

ZIP/
Postal Code

Country

3. Telephone

Alt. Phone

E-mail Address

Preferred method of
communication:

4. Your Occupation

B.

ATTORNEY’S INFORMATION (If Applicable - See Instructions)

1. Attorney’s Name

2. Firm Name

3. Street Address

City

4. Telephone

C.

State/
Province

ZIP/
Postal Code

Fax

E-mail Address

Country

TELL US ABOUT THE INDIVIDUAL OR ENTITY YOU HAVE A COMPLAINT AGAINST
If an individual, specify profession:

Individual/Entity 1:
1. Type:

Individual

Entity

If an entity, specify type:

2. Name
Apartment/
Unit #

3. Street Address

City

State/
Province

ZIP/
Postal Code

4. Phone

E-mail Address

Internet address

- 153 -

Country

If an individual, specify profession:

Individual/Entity 2:
1. Type:

Individual

If an entity, specify type:

Entity

2. Name
Apartment/
Unit #
3. Street Address

City

4. Phone

D.

State/
Province

ZIP/
Postal Code

E-mail Address

Internet Address

Country

TELL US ABOUT YOUR COMPLAINT

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

/

/

2. Nature of complaint:

3. Are you complaining about an entity of which you are
or were an officer, director, employee, consultant or contractor?

4a. Have you taken any prior action regarding your complaint?
4b. If you answered “yes” to question 4a, please provide details. Use additional sheets if necessary.

4c. Date on which you took the action(s) described in question 4b (mm/dd/yyyy):

/

YES

NO

YES

NO

/

5a. Type of security or investment, if relevant
5c. Security/
5b. Name of issuer or security, if relevant
Ticker Symbol or CUSIP no.
6. State in detail all facts pertinent to the alleged violation. Explain why you believe the acts described constitute a violation of the federal
securities laws. Use additional sheets if necessary.

- 154 -

7. Describe all supporting materials in your possession and the availability and location of any additional supporting materials not in your
possession. Use additional sheets, if necessary.

8. Describe how you obtained the information that supports this claim. If any information was obtained from a public source, identify the
source with as much particularity as possible. Attach additional sheets if necessary.

9. Provide any additional information you think may be relevant.

- 155 -

Privacy Act Statement
This notice is given under the Privacy Act of 1974. The Privacy Act requires that the Securities and
Exchange Commission (SEC) inform individuals of the following when asking for information. This form
may be used by anyone wishing to provide the SEC with information concerning a violation of the federal
securities laws. If you are submitting information for the SEC’s whistleblower award program pursuant to
Section 21F of the Securities Exchange Act of 1934 (Exchange Act), the information provided will enable
the Commission to determine your eligibility for payment of an award. The information provided may be
disclosed to federal, state, local, or foreign agencies responsible for investigating, prosecuting, enforcing,
or implementing the federal securities laws, rules, or regulations consistent with the confidentiality
requirements set forth in Section 21F(h)(2) of the Exchange Act and Rule 21F-7 thereunder.
If you are submitting information for the SEC’s whistleblower award program anonymously, you must be
represented by an attorney and you must provide the information requested about your attorney on this
form. Otherwise, furnishing the information requested herein is voluntary.

Questions concerning this form may be directed to the SEC Whistleblower Office, 100 F Street, NE,
Washington, D.C. 20549-XXXX, Tel. (800) XXX-XXXX, Fax (202) XXX-XXXX

Submission Procedures
•

After manually completing this Form TCR, please send it by mail or delivery to the SEC
Whistleblower Office, 100 F. Street, NE, Washington, D.C. 20549-XXXX, or by facsimile to (202)
XXX-XXXX.

•

You have the right to submit information anonymously. If you are submitting anonymously and
you want to be considered for a whistleblower award, however, you must be represented by an
attorney in this matter and Section B of this form must be completed. Otherwise, you may, but
are not required, to have an attorney. If you are not represented by an attorney in this matter,
you may leave Section B blank.

•

If you are submitting information for the SEC’s whistleblower award program, you must
submit your information either using this Form TCR or electronically through the SEC’s
- 156 -

Electronic Data Collection System, available on the SEC web site at [insert link]. In
addition to submitting your information by either of these methods, you must also submit
a declaration on Form WB-DEC. The Form WB-DEC can be printed out from our web site or
obtained from the SEC Whistleblower Office, and it must be manually signed by you under
penalty of perjury. To learn more about this program and its special requirements, please visit
the Whistleblower Office’s website at [INSERT LINK].

Instructions for Completing Form TCR:

Section A: Information about You

Questions 1-3: Please provide the following information about yourself:
•

Last name, first name, and middle initial

•

Complete address, including city, state and zip code

•

Telephone number and, if available, an alternate number where you can be reached

•

Your e-mail address (to facilitate communications, we strongly encourage you to provide
your email address), and

•

Your preferred method of communication.

Question 4: State which of the following best describes your occupation:
•

accountant, attorney, auditor, broker-dealer, compliance officer, financial representative,
foreign officer, fund manager, investment advisor, investor, other company officer or
senior manager, registered representative, trader, transfer agent, underwriter,
government official (federal, state, or local), law enforcement personnel (federal, state, or
local), or other (specify).

Section B: Information about Your Attorney. Complete this section only if you are represented by
an attorney in this matter. You must be represented by an attorney, and this section must be

- 157 -

completed, if you are submitting your information anonymously and you want to be considered
for the SEC’s whistleblower award program.

Questions 1-4: Provide the following information about the attorney representing you in this matter:
•

Attorney’s name

•

Firm name

•

Complete address, including city, state and zip code

•

Telephone number and fax number, and

•

E-mail address

Section C: Tell Us about the Individual and/or Entity You Have a Complaint Against. If your
complaint relates to more than two individuals and/or entities, you may attach additional sheets.

Question 1:

Choose one of the following that best describes the individual or entity to which your
complaint relates:

•

For Individuals: accountant, analyst, attorney, auditor, broker, compliance officer,
employee, executive officer or director, financial planner, fund manager, investment
advisor, stock promoter, trustee, unknown, or other (specify).

•

For Entity: bank, broker-dealer, clearing agency, day trading firm, exchange, Financial
Industry Regulatory Authority, insurance company, investment company, Individual
Retirement Account or 401(k) custodian/administrator, market maker, municipal
securities dealers, mutual fund, newsletter company/investment publication companies,
on-line trading firm, private fund company (including hedge fund, private equity fund,
venture capital fund, or real estate fund), private/closely held company, SEC or other
federal agency, transfer agent/paying agent/registrar, underwriter, unknown, or other
(specify).

Questions 2-4: F
or each subject, provide the following information, if known:
•

Full name
- 158 -

•

Complete address, including city, state and zip code

•

Telephone number,

•

E-mail address, and

•

Internet address, if applicable

Section D: Tell Us about Your Complaint
Question 1:

State the date (mm/dd/yyyy) that the alleged conduct began.

Question 2:

Choose the option that you believe best describes the nature of your complaint. If you
are alleging more than one violation, please list all that you believe may apply. Use
additional sheets if necessary.

•

Theft/misappropriation (advance fee fraud; lost or stolen securities; hacking of account)

•

Misrepresentation/omission (false/misleading marketing/sales literature; inaccurate,
misleading or non-disclosure by Broker-Dealer, Investment Adviser and Associated
Person; false/material misstatements in firm research that were basis of transaction)

•

Offering fraud (Ponzi/pyramid scheme; other offering fraud)

•

Registration violations (unregistered securities offering)

•

Trading (after hours trading; algorithmic trading; front-running; insider trading,
manipulation of securities/prices; market timing; inaccurate quotes/pricing information;
program trading; short selling; trading suspensions; volatility)

•

Fees/mark-ups/commissions (excessive or unnecessary administrative fees; excessive
commissions or sales fees; failure to disclose fees; insufficient notice of change in fees;
negotiated fee problems; excessive mark-ups/markdowns; excessive or otherwise
improper spreads)

•

Corporate disclosure/reporting/other issuer matter (audit; corporate governance; conflicts
of interest by management; executive compensation; failure to notify shareholders of
corporate events; false/misleading financial statements, offering documents, press
releases, proxy materials; failure to file reports; financial fraud; Foreign Corrupt Practices
Act violations; going private transactions; mergers and acquisitions; restrictive legends,
- 159 -

including 144 issues; reverse stock splits; selective disclosure – Regulation FD, 17 CFR
243; shareholder proposals; stock options for employees; stock splits; tender offers)
•

Sales and advisory practices (background information on past violations/integrity; breach
of fiduciary duty/responsibility (IA); failure to disclose breakpoints; churning/excessive
trading; cold calling; conflict of interest; abuse of authority in discretionary trading; failure
to respond to investor; guarantee against loss/promise to buy back shares; high pressure
sales techniques; instructions by client not followed; investment objectives not followed;
margin; poor investment advice; Regulation E (Electronic Transfer Act); Regulation S-P,
17 CFR 248, (privacy issues); solicitation methods (non-cold calling; seminars);
suitability; unauthorized transactions)

•

Operational (bond call; bond default; difficulty buying/selling securities;
confirmations/statements; proxy materials/prospectus; delivery of funds/proceeds;
dividend and interest problems; exchanges/switches of mutual funds with fund family;
margin (illegal extension of margin credit, Regulation T restrictions, unauthorized margin
transactions); online issues (trading system operation); settlement (including T+1 or T=3
concerns); stock certificates; spam; tax reporting problems; titling securities (difficulty
titling ownership); trade execution.

•

Customer accounts (abandoned or inactive accounts; account administration and
processing; identity theft affecting account; IPOs: problems with IPO allocation or
eligibility; inaccurate valuation of Net Asset Value; transfer of account)

•

Comments/complaints about SEC, Self-Regulatory Organization, and Securities Investor
Protection Corporation processes & programs (arbitration: bias by arbitrators/forum,
failure to pay/comply with award, mandatory arbitration requirements, procedural
problems or delays; SEC: complaints about enforcement actions, complaints about
rulemaking, failure to act; Self-Regulatory Organization: failure to act; Investor Protection:
inadequacy of laws or rules; SIPC: customer protection, proceedings and Broker-Dealer
liquidations;

- 160 -

•

Other (analyst complaints; market maker activities; employer/employee disputes; specify
other).

Question 3:

Indicate whether you were in the past, or are currently, an officer, director, employee,
consultant, or contractor of the entity to which your complaint relates.

Question 4a:

Indicate whether you have taken any prior action regarding your complaint, including
whether you reported the violation to the entity, including the compliance office,
whistleblower hotline or ombudsman; complained to the SEC, another regulator, a law
enforcement agency, or any other agency or organization; initiated legal action, mediation
or arbitration, or initiated any other action.

Question 4b:

If you answered “yes” to question 4a, provide details, including the date on which you
took the action(s) described, the name of the person or entity to whom you directed any
report or complaint and contact information for the person or entity, if known, and the
complete case name, case number, and forum of any legal action you have taken. Use
additional sheets if necessary.

Question 5a:

Choose from the following the option that you believe best describes the type of security
or investment at issue, if applicable:
y 1031 exchanges
y 529 plans
y American Depositary Receipts
y Annuities (equity-indexed annuities, fixed annuities, variable annuities)
y Asset-backed securities
y Auction rate securities
y Banking products (including credit cards)
y Certificates of deposit (CDs)
y Closed-end funds
y Coins and precious metals (gold, silver, etc.)
y Collateralized mortgage obligations (CMOs)
y Commercial paper

- 161 -

y Commodities (currency transactions, futures, stock index options)
y Convertible securities
y Debt (corporate, lower-rated or “junk”, municipal)
y Equities (exchange-traded, foreign, Over-the-Counter, unregistered, linked notes)
y Exchange Traded Funds
y Franchises or business ventures
y Hedge funds
y Insurance contracts (not annuities)
y Money-market funds
y Mortgage-backed securities (mortgages, reverse mortgages)
y Mutual funds
y Options (commodity options, index options)
y Partnerships
y Preferred shares
y Prime bank securities/high yield programs
y Promissory notes
y Real estate (real estate investment trusts (REITs))
y Retirement plans ( 401(k), IRAs)
y Rights and warrants
y Structured note products
y Subprime issues
y Treasury securities
y U.S. government agency securities
y Unit investment trusts (UIT)
y Viaticals and life settlements
y Wrap accounts
y Separately Managed Accounts (SMAs)
y Unknown

- 162 -

y Other (specify)
Question 5b:

Provide the name of the issuer or security, if applicable.

Question 5c:

Provide the ticker symbol or CUSIP number of the security, if applicable.

Question 6:

State in detail all the facts pertinent to the alleged violation. Explain why you believe the
facts described constitute a violation of the federal securities laws. Attach additional
sheets if necessary.

Question 7:

Describe all supporting materials in your possession and the availability and location of
additional supporting materials not in your possession. Attach additional sheets if
necessary.

Question 8:

Describe how you obtained the information that supports your allegation. If any
information was obtained from a public source, identify the source with as much
particularity as possible. Attach additional sheets if necessary.

Question 9:

Please provide any additional information you think may be relevant.

- 163 -