Form WB-2 Form DEC

UNITED STATES

SECURITIES AND EXCHANGE COMMISSION

Washington, D.C. 20549

FORM WB-DEC

DECLARATION OF ORIGINAL INFORMATION SUBMITTED

PURSUANT TO SECTION 21F OF THE SECURITIES EXCHANGE ACT OF 1934

A.

SUBMITTER’S INFORMATION

1. Last Name

M.I.

First

Apartment/
Unit #

2. Street Address
City

State/
Province

ZIP Code

3. Telephone

Alt. Phone

E-mail Address

B.

Country

ATTORNEY INFORMATION (If Applicable - See Instructions)

1. Attorney’s name
2. Firm Name
3. Street Address
City

State/
Province

ZIP Code

4. Telephone

Fax

E-mail Address

C.

Country

TIP/COMPLAINT DETAILS

1. Manner in which information was submitted to SEC:
2a. Tip, Complaint or Referral (TCR) number:
(Required if you submitted your information through SEC website)

SEC website

Mail

Fax

Other

______________

2b. Date TCR referenced in 2a submitted to SEC

/

/

2c. Individual or entity to which Tip, Complaint or Referral relates:
3a. Has the submitter or counsel had any communication(s) with the SEC concerning this matter?

YES

NO

3b. If the answer to 3a is “Yes,” name of SEC staff member with whom the submitter or counsel communicated
4a. Has the submitter or counsel provided the information to any other agency or organization?
4b. If the answer to 4a is “Yes,” please provide details. Use additional sheets if necessary

YES

NO

4c. Name and contact information for point of contact at agency or organization, if known

D.

ELIGIBILITY REQUIREMENTS

1. Are you, or were you at the time you acquired the original information you submitted to us, a member, officer or employee of the
Department of Justice, the Securities and Exchange Commission, the Comptroller of the Currency, the Board of Governors of the Federal
Reserve System, the Federal Deposit Insurance Corporation, the Office of Thrift Supervision; the Public Company Accounting Oversight
Board; any law enforcement organization; or any national securities exchange, registered securities association, registered clearing agency,
the Municipal Securities Rulemaking Board?
YES
NO

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2. Are you, or were you at the time you acquired the original information you submitted to us, a member, officer or employee of a foreign
government, any political subdivision, department, agency, or instrumentality of a foreign government, or any other foreign financial regulatory
authority as that term is defined in Section 3(a)(52) of the Securities Exchange Act of 1934 (15 U.S.C. §78c(a)(52))?
YES
NO
3. Did you obtain the information you are providing to us through the performance of an engagement required under the federal securities
laws by an independent public accountant ?
YES
NO
4. Did you provide the information identified in Section C above pursuant to a cooperation agreement with the SEC or another agency or
organization?
YES
NO
5. Are you a spouse, parent, child, or sibling of a member or employee of the Commission, or do you reside in the same household as a
member or employee of the Commission?
YES
NO
6. Did you acquire the information you are providing to us from any person described in questions D1 through D5?
YES
NO
7. If you answered “yes” to any of questions 1 through 6 above, please provide details. Use additional sheets if necessary.

8a. Did you provide the information identified in Section C above before you (or anyone representing you) received any request, inquiry or
demand from the SEC, Congress, or any other federal, state or local authority, or any self regulatory organization, or the Public Company
Accounting Oversight Board about a matter to which the information your submission was relevant?
YES
NO
8b. If you answered “no” to question 8a, please provide details. Use additional sheets if necessary.

9a. 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 upon which your application for an award is based?
YES
NO
9b. If you answered “Yes” to question 9a, please provide details. Use additional sheets if necessary.

E. DECLARATION
I declare under penalty of perjury under the laws of the United States that the information contained herein, and all information submitted to
the SEC – either in the TCR referenced in Section C of this form or in the Form TCR accompanying this Form WB-DEC - 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 SEC, 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.
Date

Signature

F. COUNSEL CERTIFICATION
I certify that I have verified the identity of the whistleblower who completed Form WB-DEC in connection with the information referenced in
Section C of this form by viewing the whistleblower’s valid, unexpired government issued identification (e.g., driver’s license, passport), that I
have reviewed the whistleblower’s Form WB-DEC for completeness and accuracy, and that I will retain an original, signed copy of the Form
WB-DEC completed by the whistleblower in my records.
Signature

Date

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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. The
information provided will enable the Commission to determine your eligibility for payment of an award
pursuant to Section 21F of the Securities Exchange Act of 1934. This information 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 21F-7 of this chapter. Furnishing the
information is voluntary, but a decision not to do so may result in you not being eligible for award
consideration.

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.

General Information
•

Submitting information for the SEC’s whistleblower award program is a two-step process. First,
you must provide us with your information, which you may do in either of two ways. You may
submit information electronically through the SEC’s Electronic Data Collection System available
on the SEC web site at [insert link]. Utilizing the SEC’s online database is quick and easy and will
enable you to print and retain a date and time-stamped confirmation of the information you
provided to us. If you prefer, you may compete Form TCR (“Tip, Complaint, or Referral”)
manually, and mail or deliver it to us in hard copy following the instructions set forth on the form.

•

Submitting your information to us is the first step. If you want to be considered for a
whistleblower award, you must also submit this Form WB-DEC and it must be manually
signed under penalty of perjury.

•

If you submitted your information electronically through our web site, we must receive
your completed Form WB-DEC within 30 days of your submission. If you did not submit
your information electronically but instead are submitting your information on Form TCR,
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you must submit your declaration on Form WB-DEC at the same time that you submit your
Form TCR. Follow the instructions set forth below for submitting this Form WB-DEC.
•

If you follow these steps, and the information you submit leads to the successful enforcement of
an SEC judicial or administrative action, or a related action, you will have an opportunity at a later
date to submit a claim for an award. That is a separate process and is described in our
whistleblower rules, which are available at [insert link for WBO website].

•

You have the right to submit information anonymously. If you are doing so, please skip Part I of
these instructions and proceed directly to Part II. Otherwise, please begin by following the
instructions in Part I.

Part I: Instructions for filers who are disclosing their identity
•

You are required to complete Sections A, C, D, and E of this form. If you are represented by an
attorney in this matter, you must also complete Section B. Specific instructions for answering these
questions can be found in Part IV below.

•

If you previously submitted your complaint electronically through the SEC’s web site, you may submit
this Form WB-DEC to us in any of the following ways:
o By mailing or delivering the signed form to the SEC Whistleblower Office, 100 F Street NE,
Washington, D.C. 20549-XXXX; or
o By faxing the signed form to (202) XXX-XXXX; or
o By scanning and emailing the form in PDF format to [insert email address].
Please note that we must receive your Form WB-DEC within thirty (30) days of when you
submitted your information to us through our web site.

•

If you did not previously submit your complaint electronically through the SEC’s web site, but instead
intend to send us a Form TCR, then you must submit your completed Form TCR and your declaration
on this Form WB-DEC together. You may do so in one of two ways:

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o By mailing or delivering the form TCR and the signed form WB-DEC to the SEC
Whistleblower Office, 100 F Street NE, Washington, D.C. 20549-XXXX; or
o By faxing the form TCR and the signed form WB-DEC form to (202) XXX-XXXX.

Part II: Instructions for anonymous filers
•

If you are submitting information anonymously, you must be represented by an attorney in this matter.

•

If you previously submitted your complaint anonymously through the SEC’s web site, make sure your
attorney knows this.

•

If you or your attorney did not previously submit your complaint electronically through the SEC’s web
site, but instead sent a Form TCR to us, then complete your Form TCR and give it to your attorney.

•

You are also required to complete Sections B, C, D, and E of this form, and give the signed original to
your attorney. Specific instructions for answering these questions can be found in Part IV below.

•

In order for you to be eligible for a whistleblower award, your attorney must retain your signed original
of Form WB-DEC in his or her records, and submit both your Form TCR (if you filled one out instead
of submitting your complaint to us electronically) and an attorney declaration to us. You are
encouraged to confirm that your attorney followed these steps.

Part III: Instructions for attorneys representing anonymous whistleblowers
•

Obtain a completed and signed original of Form WB-DEC from your client. You must retain this
signed original in your records because it may be required at a later date if your client files a claim for
a whistleblower award.

•

You must prepare your own Form WB-DEC, completing only Sections B, C and F. Specific
instructions for answering these questions can be found in Part IV below.

•

If your client previously submitted his or her complaint electronically through the SEC’s web site, you
may submit your attorney Form WB-DEC to us in any of the following ways:
o By mailing or delivering the signed form to the SEC Whistleblower Office, 100 F Street NE,
Washington, D.C. 20549-XXXX; or
o By faxing the signed form to (202) XXX-XXXX; or
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o By scanning and emailing the form in PDF format to [insert email address].
Please note that we must receive your Form WB-DEC within thirty (30) days of when your
client submitted the information to us through our web site.
•

If your client did not previously submit his or her complaint electronically through the SEC’s web site,
but instead intends to submit a Form TCR to us, then you must submit your client’s complaint on
Form TCR and your attorney declaration on this Form WB-DEC together. You may do so in one of
two ways:
o By mailing or delivering the Form TCR and the signed Form WB-DEC to the SEC
Whistleblower Office, 100 F Street NE, Washington, D.C. 20549-XXXX; or
o By faxing the Form TCR and the signed Form WB-DEC to (202) XXX-XXXX.

Part IV: Instructions for Completing Form WB-DEC:
Section A: Submitter’s Information
Questions 1-3: Provide the following information about yourself:
•

First and last 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

•

E-mail address

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
completed, if you submitted your information anonymously.

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

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•

E-mail address

Section C: Tip/Complaint Details
Question 1:

Indicate the manner in which the information was submitted to the SEC.

Question 2a: Include the TCR (Tip, Complaint or Referral) number, if available. THE TCR NUMBER
MUST BE INCLUDED ON FORM WB-DEC IN CASES WHERE THE ORIGINAL
INFORMATION WAS SUBMITTED THROUGH THE SEC WEBSITE
Question 2b: Provide the date on which the TCR referenced in 2a was submitted to the SEC.
Question 2c:

Provide the name of the individual or entity to which your complaint relates.

Question 3a:

Indicate whether the submitter or counsel have had any communication(s) with the SEC
concerning this manner.

Question 3b: If you answered “yes” to question 3a, provide the name of the SEC staff member with
whom the submitter or counsel communicated.
Question 4a: Indicate whether the submitted or counsel have provided the information being submitted
to the SEC to any other agency or organization.
Question 4b: If you answered “yes” to question 4a, provide details, including the name of the agency or
organization, the date on which you provided your information to the agency or
organization and any other relevant details.
Question 4c: Provide a name and contact information for your point of contact at the other agency or
organization, if known.

Section D: Eligibility Requirements
Question 1:

State whether you are currently, or were at the time you acquired the original information
that you submitted to the SEC a member, officer, or employee of the Department of
Justice; the Securities and Exchange Commission; the Comptroller of the Currency, the
Board of Governors of the Federal Reserve System, the Federal Deposit Insurance
Corporation, or the Office of Thrift Supervision; the Public Company Accounting

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Oversight Board; any law enforcement organization; or any national securities exchange,
registered securities association, registered clearing agency, the Municipal Securities
Rulemaking Board
Question 2:

State whether you are, or were you at the time you acquired the original information you
submitted to the SEC, a member, officer or employee of a foreign government, any
political subdivision, department, agency, or instrumentality of a foreign government, or
any other foreign financial regulatory authority as that term is defined in Section 3(a)(52)
of the Securities Exchange Act of 1934.
•

Section 3(a)(52) of the Exchange Act (15 U.S.C. §78c(a)(52)) currently defines
‘‘foreign financial regulatory authority’’ as “any (A) foreign securities authority, (B)
other governmental body or foreign equivalent of a self-regulatory organization
empowered by a foreign government to administer or enforce its laws relating to
the regulation of fiduciaries, trusts, commercial lending, insurance, trading in
contracts of sale of a commodity for future delivery, or other instruments traded
on or subject to the rules of a contract market, board of trade, or foreign
equivalent, or other financial activities, or (C) membership organization a function
of which is to regulate participation of its members in activities listed above.”

Question 3:

Indicate whether you acquired the information you provided to the SEC through the
performance of an engagement required under the securities laws by an independent
public accountant.

Question 4:

State whether you provided the information submitted to the SEC pursuant to a
cooperation agreement with the SEC or with any other agency or organization.

Question 5:

State whether you are a spouse, parent, child or sibling of a member or employee of the
Commission, or whether you reside in the same household as a member or employee of
the Commission.

Question 6:

State whether you acquired the information you are providing to the SEC from any
individual described in Question 1 through 5 of this Section.

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Question 7:

If you answered “yes” to questions 1 though 6, please provide details.

Question 8a:

State whether you provided the information identified submitted to the SEC before you (or
anyone representing you) received any request, inquiry or demand from the SEC,
Congress, or any other federal, state or local authority, or any self regulatory
organization, or the Public Company Accounting Oversight Board about a matter to which
the information your submission was relevant.

Question 8b:

If you answered “no” to questions 8a, please provide details. Use additional sheets if
necessary.

Question 9a: State whether you are the subject or target of a criminal investigation or have been
convicted of a criminal violation in connection with the information upon which your
application for award is based.
Question 9b: If you answered “yes” to question 7a, please provide details, including the name of the
agency or organization that conducted the investigation or initiated the action against
you, the name and telephone number of your point of contact at the agency or
organization, if available and the investigation/case name and number, if applicable. Use
additional sheets, if necessary.

Section E: Declaration
To be completed and signed by person submitting the information

Section F: Counsel Certification
To be completed and signed by attorney for an anonymous person submitting information

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