Form TCR Form TCR -- Tip, Complaint or Referral

UNITED STATES
COMMODITY FUTURES TRADING COMMISSION
Washington, D.C. 20581
FORM TCR
TIP, COMPLAINT OR REFERRAL

A. INFORMATION ABOUT YOU
COMPLAINANT 1:
1. Last Name

First Name

M.I.

2. Street Address

Apartment/Unit #

City

State/Province

ZIP/Postal Code

Country

3. Telephone

Alt. Phone

E-mail Address

Preferred Method of
Communication

4. Occupation

COMPLAINANT 2:
1. Last Name

First Name

M.I.

2. Street Address

Apartment/Unit #

City

State/Province

ZIP/Postal Code

Country

3. Telephone

Alt. Phone

E-mail Address

Preferred Method of
Communication

4. Occupation

B. ATTORNEY’S INFORMATION (If Applicable - See Instructions)
1. Attorney’s Name

2. Firm Name

3. Street Address

City

State/Province

ZIP/Postal Code

4. Telephone

Fax

E-mail Address

Country

C. TELL US ABOUT THE INDIVIDUAL AND/OR ENTITY THE WHISTLEBLOWER HAS A
COMPLAINT AGAINST
INDIVIDUAL/ENTITY 1:
1. Type:

Individual

Entity

If An Individual, Specify Profession, If An Entity, Specify Type:

2. Name
3. Street Address

Apartment/Unit #

City

State/Province

4. Phone

E-mail Address

ZIP/Postal Code

Country

Internet Address

INDIVIDUAL/ENTITY 2:
1. Type:

Individual

Entity

If An Individual, Specify Profession, If An Entity, Specify Type:

2. Name
3. Street Address

Apartment/Unit #

City

State/Province

4. Phone:

E-mail Address:

ZIP/Postal Code

Country

Internet Address:

D.

TELL US ABOUT THE WHISTLEBLOWER’S COMPLAINT

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

2. Nature of Complaint:

3a. Has the complainant or counsel had any prior communication(s) with the CFTC concerning this matter? YES

NO

3b. If the answer to 3a is “Yes,” name of CFTC staff member with whom the complainant or counsel communicated.

4a. Have you or your counsel provided the information to any other agency or organization, or has any other agency or organization
requested the information or related information from you? YES
NO
4b. If the answer to 4a is “Yes,” please provide details. Use additional sheets, if necessary.

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

5a. Does this complaint relate to an entity of which the complainant is or was an officer, director, counsel, employee, consultant or
contractor? YES
NO
5b. If the answer to question 5a is “yes,” has the complainant reported this violation to his or her supervisor, compliance office,
whistleblower hotline, ombudsman, or any other available mechanism at the entity for reporting violations? YES
NO
5c. If the answer to question 5b is “yes,” please provide details. Use additional sheets, if necessary.

5d. Date on which the complainant took the action(s) described in question 5b (mm/dd/yyyy):
6a. Have you taken any other action regarding your complaint? YES

NO

6b. If the answer to question 6a is “yes,” please provide details. Use additional sheets, if necessary.

7a. Type of financial product or investment, if relevant.

7b. Name of financial product or investment, if relevant.

8. State in detail all facts pertinent to the alleged violation. Explain why the complainant believes the facts described constitute a
violation of the Commodity Exchange Act (CEA). Use additional sheets, if necessary.

9. Describe all supporting materials in the complainant’s possession and the availability and location of any additional supporting
materials not in complainant’s possession. Use additional sheets, if necessary.

10. Describe how and from whom the complainant obtained the information that supports this claim. 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. Use additional sheets, if necessary.

11. Identify with particularity any documents or other information in the whistleblower’s submission that the whistleblower
believes could reasonably be expected to reveal the whistleblower’s identity and explain the basis for the whistleblower’s belief that
the whistleblower’s identity would be revealed if the documents or information were disclosed to a third party.

12. Provide any additional information the whistleblower thinks may be relevant.

E.

ELIGIBILITY REQUIREMENTS AND OTHER INFORMATION

1. Are you, or was the whistleblower at the time the whistleblower acquired the original information the whistleblower is submitting
to the Commission a member, officer or employee of the Department of Justice, the Commodity Futures Trading 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 National Credit Union Administration, the Securities and Exchange Commission, a registered
entity, a registered futures association, a self-regulatory organization, or any law enforcement organization?
YES

NO

2. Is the whistleblower providing this information pursuant to a cooperation agreement with the Commodity Futures Trading
Commission or another agency or organization?
YES

NO

3. Is the whistleblower providing this information before the whistleblower (or anyone representing you) received any request,
inquiry or demand that relates to the subject matter of the whistleblower’s submission (i) from the Commodity Futures Trading
Commission, (ii) in connection with an investigation, inspection or examination by any registered entity, registered futures
association or self-regulatory organization, or (iii) in connection with an investigation by the Congress, or any other federal or state
authority?
YES

NO

4. Is the whistleblower currently a subject or target of a criminal investigation, or have the whistleblower been convicted of a
criminal violation, in connection with the information the whistleblower is submitting to the Commodity Futures Trading
Commission?
YES

NO

5. Did the whistleblower acquire the information being provided to us from any person described in questions E1 through E5?
YES

NO

6. Are you, or was the whistleblower at the time the whistleblower acquired the original information the whistleblower is submitting
to the Commission a member, officer, or employee of a foreign regulatory authority or law enforcement organization.
YES

NO

7. Use this space to provide additional details relating to the whistleblower’s responses to questions 1 through 5. Use additional
sheets, if necessary.

F. 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 whistleblower 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.
Print Name

Signature

Date

G. 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-waiveable 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 7 calendar days of receiving such a request
from the Commodity Futures Trading Commission.
Signature

Date

Privacy Act Statement
This notice is given under the Privacy Act of 1974. The Privacy Act requires that the Commodity Futures Trading
Commission (CFTC or Commission) inform individuals of the following when asking for information. The solicitation of
this information is authorized under the Commodity Exchange Act, 7 USC 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
Commission’s regulations. If an individual is submitting this information for the Commission’s whistleblower award
program pursuant to Section 23 of the Commodity Exchange Act, the information provided will be used to enable the
Commission 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 Commission regulations. This information
may be disclosed to Federal, state, local, or foreign agencies or other authorities responsible for investigating,
prosecuting, enforcing, or implementing laws, rules, or regulations implicated by the information consistent with the
confidentiality requirements set forth therein, including pursuant to Section 23 of the Commodity Exchange Act and Part
165 of the Commission’s regulations thereunder. The information will be maintained and additional disclosures may
be made in accordance with System of Records Notices CFTC-10, “Investigatory Records” (exempted), and CFTC16, “Enforcement Case Files.” Furnishing the information is voluntary. However, if an individual is providing
information for the whistleblower award program, not providing required information may result in the individual not
being eligible for award consideration.
Questions concerning this form may be directed to the Commodity Futures Trading Commission, Attention: TCR, Three
Lafayette Centre, 1155 21st Street, N.W., Washington, DC 20581.

Submission Procedures


After completing this Form TCR, please send it by mail delivery to the Commodity Futures Trading
Commission, Attention: TCR, Three Lafayette Centre, 1151 21st Street, N.W., Washington, DC 20581; or
by facsimile to (202) 418-5975.



The whistleblower has the right to submit information anonymously. However, for a whistleblower to
receive a whistleblower award, the whistleblower will need to be identified to selected Commission staff
for a final eligibility determination, and in unusual circumstances, may need to be identified publicly for
trial.



If the whistleblower is submitting information for the Commission’s whistleblower award program, the
whistleblower must submit the whistleblower’s information using this Form TCR.

Instructions for Completing Form TCR:
Section A: Information About You
Questions 1-4: 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 the whistleblower can be reached;



The whistleblower’s e-mail address (to facilitate communications, we strongly encourage the
whistleblower to provide the whistleblower’s email address);



The whistleblower’s preferred method of communication; and



The whistleblower’s occupation.

Section B: Information about the Whistleblower’s Attorney. Complete this section only if the whistleblower
is represented by an attorney in this matter.
Questions 1-4: Provide the following information about the attorney representing the whistleblower 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 The Whistleblower Has a Complaint Against. If the
whistleblower’s complaint relates to more than two individuals and/or entities, the whistleblower may use additional
sheets, if necessary.

Question 1:

Choose one of the following that best describes the individual’s profession or entity’s type to
which the whistleblower’s complaint relates:


For Individuals: accountant, analyst, associated person, attorney, auditor, broker, commodity
trading advisor, commodity pool operator, compliance officer, employee, executing broker,
executive officer or director, financial planner, floor broker, floor trader, trader, unknown, or
other (specify).



For Entities: bank, commodity trading advisor, commodity pool operator, commodity
pool, futures commission merchant, hedge fund, introducing broker, major swap
participant, retail foreign exchange dealer, swap dealer, unknown, or other (specify).

Questions 2-4: For each individual and/or entity, provide the following information, if known:


Full name;



Complete address, including city, state and zip code;



Telephone number;



E-mail address; and



Internet address, if applicable.

Section D: Tell Us About the Whistleblower’s Complaint
Question 1:

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

Question 2:

Choose the option that the whistleblower believes best describes the nature of the whistleblower’s
complaint. If the whistleblower is alleging more than one violation, please list all that the
whistleblower believes may apply. Use additional sheets, if necessary.


Theft/misappropriation;



Misrepresentation/omission (i.e., false/misleading marketing/sales literature; inaccurate,
misleading or non-disclosure by commodity pool operator, commodity trading advisor,
futures commission merchant, introducing broker, retail foreign exchange dealer, major
swap participant, swap dealer, or their associated person(s); false/material
misstatements in any report or statement);



Ponzi/pyramid scheme;



Off-exchange foreign currency, commodity, or precious metal fraud;



Registration violations (including unregistered commodity pool operator; commodity
trading advisor; futures commission merchant; introducing broker; retail foreign
exchange dealer; swap dealer; or their associated person(s));



Trading (after hours trading; algorithmic trading; disruptive trading; front running; insider
trading; manipulation/attempted manipulation of commodity prices; market timing; inaccurate
quotes/pricing information; program trading; trading suspensions; volatility);



Fees/mark-ups/commissions (excessive, unnecessary or unearned administrative, commission
or sales fees; failure to disclose fees; insufficient notice of change in fees; excessive or otherwise
improper spreads or fills);



Sales and advisory practices (background information on past violations/integrity; breach of
fiduciary duty/responsibility; churning/excessive trading; cold calling; conflict of interest; abuse
of authority in discretionary trading; failure to respond to client, customer or participant;
guarantee against loss; promise to profit; high pressure sales techniques; instructions by client,
customer or participant not followed; investment objectives not followed; solicitation methods
(e.g., cold calling, seminars);



Customer accounts (unauthorized trading); identity theft affecting account; inaccurate valuation
of Net Asset Value; or


Question 3a:

Other (analyst complaints; market maker activities; employer/employee disputes; specify other).
State whether the whistleblower or the whistleblower’s counsel has had any prior communications
with the CFTC concerning this matter.

Question 3b:

If the answer to question 3a is yes, provide the name of the CFTC staff member with whom the
whistleblower or the whistleblower’s counsel communicated.

Question 4a:

Indicate whether the whistleblower or the whistleblower’s counsel has provided the information
the whistleblower is providing to the CFTC to any other agency or organization.

Question 4b:

If the answer to question 4a is yes, provide details.

Question 4c:

Provide the name and contact information of the point of contact at the other agency or
organization, if known.

Question 5a:

Indicate whether the whistleblower’s complaint relates to an entity of which the whistleblower is,
or was in the past, an officer, director, counsel, employee, consultant, or contractor.

Question 5b:

If the answer to question 5a is yes, state whether the whistleblower has reported this violation to
the whistleblower’s supervisor, compliance office, whistleblower hotline, ombudsman, or any
other available mechanism at the entity for reporting violations.

Question 5c:

If the answer to question 5b is yes, provide details.

Question 5d:

Provide the date on which the whistleblower took the actions described in questions 5a and 5b.

Question 6a:

Indicate whether the whistleblower has taken any other action regarding the whistleblower’s
complaint, including whether the whistleblower complained to the Commission, another
regulator, a law enforcement agency, or any other agency or organization; initiated legal action,
mediation or arbitration, or initiated any other action.

Question 6b:

If the whistleblower answered yes to question 6a, provide details, including the date on which the
whistleblower took the action(s) described, the name of the person or entity to whom the
whistleblower 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 the
whistleblower has taken. Use additional sheets, if necessary.

Question 7a:

Choose from the following the option that the whistleblower believes best describes the type of
financial product or investment at issue, if applicable:
 Commodity futures;
 Options on commodity futures;
 Commodity options;
 Foreign currency transactions;
 Swaps; or
 Other (specify).

Question 7b:

Provide the name of the financial product or investment, if applicable.

Question 8:

State in detail all the facts pertinent to the alleged violation. Explain why the whistleblower
believes the facts described constitute a violation of the Commodity Exchange Act. Use
additional sheets, if necessary.

Question 9:

Describe all supporting materials in the whistleblower’s possession, custody or control, and the
availability and location of additional supporting materials not in the whistleblower’s possession,
custody or control. Use additional sheets, if necessary.

Question 10:

Describe how the whistleblower obtained the information that supports the whistleblower’s
allegation. 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. Use additional sheets, if necessary.

Question 11:

The whistleblower may use this space to identify any documents or other information in the
whistleblower’s submission on this Form TCR that the whistleblower believes could reasonably
be expected to reveal the whistleblower’s identity. Explain the basis for the whistleblower’s belief
that the whistleblower’s identity would be revealed if the documents or information were
disclosed to a third party.

Question 12:

Provide any additional information the whistleblower thinks may be relevant.

Section E: Eligibility Requirements
Question 1:

State whether the whistleblower is currently, or was at the time the whistleblower acquired the
original information that the whistleblower is submitting to the Commodity Futures Trading
Commission, a member, officer or employee of the Department of Justice, the Commodity Futures
Trading Commission, the Comptroller of the Currency, the Board of Governors of the Federal
Reserve System, the Federal Deposit Insurance Corporation, the Office Thrift Supervision,
National Credit Union Administration, the Securities and Exchange Commission, a registered
entity, a registered futures association, a self-regulatory organization, or any law enforcement
organization.

Question 2:

State whether the whistleblower is providing the information pursuant to a cooperation agreement
with the Commodity Futures Trading Commission or with any other agency or organization.

Question 3:

State whether the whistleblower is providing this information before the whistleblower (or anyone
representing you) received any request, inquiry or demand that relates to the subject matter of the

whistleblower’s 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; or (iii) in connection with an investigation by the Congress, or any other federal or
state authority.
Question 4:

State whether the whistleblower is currently a subject or target of a criminal investigation, or has
the whistleblower been convicted of a criminal violation, in connection with the information the
whistleblower is submitting to the Commodity Futures Trading Commission.

Question 5:

State whether the whistleblower acquired the information the whistleblower is providing to the
Securities and Exchange Commission from any individual described in Questions 1 through 5 of
this Section.

Question 6:

State whether the whistleblower is currently, or was at the time the whistleblower acquired the
original information that the whistleblower is submitting to the Commodity Futures Trading
Commission, a member, officer, or employee of a foreign regulatory authority or law enforcement
organization.

Question 7:

Use this space to provide additional details relating to the whistleblower’s responses to questions 1
through 6. Use additional sheets, if necessary.

SECTION F: Whistleblower’s Declaration.
The whistleblower must sign this Declaration if the whistleblower is submitting this information pursuant
to the Commodity Futures Trading Commission whistleblower program and wish to be considered for an award. If
the whistleblower is submitting the whistleblower’s information anonymously, the whistleblower must still sign this
Declaration, and the whistleblower must provide the whistleblower’s attorney with the original of this signed form.
If the whistleblower is not submitting the whistleblower’s information pursuant to the Commodity Futures
Trading Commission whistleblower program, the whistleblower do not need to sign this Declaration.
SECTION G: Counsel Certification
If the whistleblower is submitting this information pursuant to the Commodity Futures Trading
Commission whistleblower program and is doing so anonymously through an attorney, the whistleblower’s attorney
must sign the Counsel Certification section.

If the whistleblower is represented in this matter but the whistleblower is not submitting the
whistleblower’s information pursuant to the Commodity Futures Trading Commission whistleblower program, the
whistleblower’s attorney does not need to sign the Counsel Certification Section.