FORM WB-APP (Application for Award for Original Information S

UNITED STATES
COMMODITY FUTURES TRADING COMMISSION
Washington, D.C. 20581
FORM WB-APP
APPLICATION FOR AWARD FOR ORIGINAL INFORMATION SUBMITTED
PURSUANT TO SECTION 23 OF THE COMMODITY EXCHANGE ACT
A. APPLICANT’S INFORMATION (REQUIRED FOR ALL SUBMISSIONS)
1. Last Name:
First:
M.I.:
SSN Last Four Digits:

2. Street Address:

Apartment/Unit #:

City:

State/Province:

ZIP/Postal Code:

3. Telephone:

Alt. Phone:

E-mail Address:

Country:

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:

C. TIP/COMPLAINT DETAILS
1. Manner in which original information was submitted to CFTC
CFTC: Website Mail Fax Other

Country:

2a. Tip, Complaint or Referral (TCR) Number:

2b. Date TCR referred to in 2a submitted to CFTC:

2c. Subject(s) of the Tip, Complaint or Referral:

D. NOTICE OF COVERED ACTION
1. Date of Notice of Covered Action to Which Claim Relates:

2. Notice Number:

3a. Case Name:

3b. Case Number:

E. CLAIMS PERTAINING TO RELATED ACTIONS
1. Name of agency or organization to which the whistleblower provided the whistleblower’s
information:

2. Name and contact information for point of contact at agency or organization, if known:

3a. Date the whistleblower provided the
whistleblower’s information (mm/dd/yyyy):

3b. Date action filed by agency/organization
(mm/dd/yyyy):

4a. Case Name:

4b. Case Number:

F. ELIGIBILITY REQUIREMENTS AND OTHER INFORMATION
1. Is the whistleblower currently, or was the whistleblower at the time the whistleblower acquired the
original information the whistleblower submitted to the CFTC, 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, any law
enforcement organization, or a foreign regulatory authority or law enforcement organization?
YES

NO

2. Did the whistleblower provide the information identified in Section C above pursuant to a
cooperation agreement with the CFTC or another agency or organization?
YES

NO

3. Did the whistleblower acquire the information the whistleblower provided to the CFTC from any
person described in questions F1 through F2?
YES

NO

4. If the whistleblower answered “yes” to any of questions 1 through 3 above, please provide details:
(Use additional sheets, if necessary)

5a. Did the whistleblower provide the information identified in Section C above 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 selfregulatory organization; or (iii) in connection with an investigation by the Congress, or any other federal
or state authority?
YES

NO

5b. If the whistleblower answered “yes” to question 5a, please provide details: (Use additional sheets, if
necessary)

6a. 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 identified in
Section C above and upon which the whistleblower’s application for an award is based?
YES

NO

6b. If the whistleblower answered “Yes” to question 6a, please provide details: (Use additional sheets, if
necessary)

G. ENTITLEMENT TO AWARD
Explain the basis for the whistleblower’s belief that the whistleblower is entitled to an award in
connection with the whistleblower’s submission of information to the CFTC, or to another agency in a
related action. Provide any additional information the whistleblower thinks may be relevant in light of
the criteria for determining the amount of an award set forth in Section 23 of the Commodities
Exchange Act and Part 165 of the Commission’s Regulations thereunder: (Include any supporting
documents in the whistleblower’s possession or control, and use additional sheets, if necessary)

H. 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 CFTC, 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

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. The information provided will enable the Commission to determine
the whistleblower’s eligibility for payment of an award pursuant to Section 23 of the Commodity
Exchange Act. 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 responsible for investigating, prosecuting, enforcing, or
implementing laws, rules, or regulations implicated by the information consistent with the
confidentiality requirements set forth in 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 CFTC-16, “Enforcement Case Files.” The Commission
requests the last four digits of a Social Security Number for use as an individual identifier to
administer and manage the whistleblower award program. Executive Order 9397 (Nov. 22, 1943)
allows Federal agencies to use the Social Security Number as an individual identifier. 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 whistleblower
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.

General


This form should be used by persons making a claim for a whistleblower award in
connection with information provided to the CFTC or to another agency in a related
action. In order to be deemed eligible for an award, the whistleblower must meet all the
requirements set forth in Section 23 of the Commodities Exchange Act and the rules
thereunder.



The whistleblower must sign the Form WB-APP as the claimant. If the whistleblower
provided the whistleblower’s information to the CFTC anonymously, the whistleblower
must now disclose the whistleblower’s identity on this form and the whistleblower’s
identity must be verified in a form and manner that is acceptable to the CFTC prior to the
payment of any award.

o If the whistleblower is filing the whistleblower’s claim in connection with
information that the whistleblower provided to the CFTC, then the
whistleblower’s Form WB-APP, and any attachments thereto, must be received
by the CFTC within ninety (90) days of the date of the Notice of Covered Action
or the date of a final judgment in a related action to which the claim relates.

o If the whistleblower is filing the whistleblower’s claim in connection with
information the whistleblower provided to another agency in a related action, then
the whistleblower’s Form WB-APP, and any attachments there to, must be
received by the Commodity Futures Trading Commission as follows:


If a final order imposing monetary sanctions has been entered in a related
action at the time the whistleblower submits the whistleblower’s claim for

an award in connection with a Commission action, the whistleblower must
submit the whistleblower’s claim for an award in that related action on the
same Form WB-APP that the whistleblower uses for the Commission
action.


If a final order imposing monetary sanctions in a related action has not
been entered at the time the whistleblower submits the whistleblower’s
claim for an award in connection with a Commission action, the
whistleblower must submit the whistleblower’s claim on Form WB-APP
within ninety (90) days of the issuance of a final order imposing sanctions
in the related action.



The whistleblower must submit the whistleblower’s Form WB-APP to us in one of the
following two ways:
o By mailing or delivering the signed form to the Commodity Futures Trading
Commission, Attention: TCR, Three Lafayette Centre, 1155 21st Street, NW,
Washington, DC 20581; or
o By faxing the signed form to (202) 418-5975.

Instructions for Completing Form WB-APP
Section A: Applicant’s Information
Questions 1-3: Provide the following information about yourself:


First and last name, and middle initial, and social security number;



Complete address, including city, state and zip code;



Telephone number and, if available, an alternate number where the whistleblower
can be reached; and



E-mail address.

Section B: Attorney’s Information. If the whistleblower is represented by an attorney in this
matter, provide the information requested. If the whistleblower is not represented by an attorney
in this matter, leave this Section blank.
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: Tip/Complaint Details
Question 1:

Indicate the manner in which the whistleblower’s original information was
submitted to the CFTC.

Question 2a: Include the TCR (Tip, Complaint or Referral) number to which this claim relates.
Question 2b: Provide the date on which the whistleblower submitted the whistleblower’s
information to the CFTC.
Question 2c: Provide the name of the individual(s) or entity(s) to which the whistleblower’s tip,
complaint, or referral related.

Section D: Notice of Covered Action
The process for making a claim for a whistleblower award begins with the publication of
a “Notice of a Covered Action” on the Commission’s website. This Notice is published
whenever a judicial or administrative action brought by the Commission results in the imposition
of monetary sanctions exceeding $1,000,000. The Notice is published on the Commission’s
website

subsequent to the entry of a final judgment or order in the action that by itself, or

collectively with other judgments or orders previously entered in the action, exceeds the
$1,000,000 threshold required for a whistleblower to be potentially eligible for an award. The
Commission will not contact whistleblower claimants directly as to Notices of Covered Actions;
prospective claimants should monitor the Commission website for such Notices.
Question 1:

Provide the date of the Notice of Covered Action to which this claim relates.

Question 2:

Provide the notice number of the Notice of Covered Action.

Question 3a: Provide the case name referenced in Notice of Covered Action.
Question 3b: Provide the case number referenced in Notice of Covered Action.

Section E: Claims Pertaining to Related Actions
Question 1:

Provide the name of the agency or organization to which the whistleblower
provided the whistleblower’s information.

Question 2:

Provide the name and contact information for the whistleblower’s point of contact
at the agency or organization, if known.

Question 3a: Provide the date on which that the whistleblower provided the whistleblower’s
information to the agency or organization referenced in question E1.

Question 3b: Provide the date on which the agency or organization referenced in question E1
filed the related action that was based upon the information the whistleblower
provided.
Question 4a: Provide the case name of the related action.
Question 4b: Provide the case number of the related action.

Section F: Eligibility Requirements and Other Information
Question 1:

State whether the whistleblower is currently, or was at the time the whistleblower
acquired the original information that the whistleblower submitted to the CFTC, 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, any law enforcement
organization, or a foreign regulatory authority or law enforcement organization.

Question 2:

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

Question 3:

State whether the whistleblower acquired the information the whistleblower
provided to the CFTC from any individual described in Question 1 through 2 of
this Section.

Question 5:

If the whistleblower answered “yes” to questions 1 through 3 of this Section,
please provide details.

Question 5a: State whether the whistleblower provided the information submitted to the CFTC
before the whistleblower (or anyone representing the whistleblower) 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 5b: If the whistleblower answered “yes” to questions 5a, please provide details. Use
additional sheets if necessary.
Question 6a: State whether the whistleblower is the subject or target of a criminal investigation,
or has been convicted of a criminal violation, in connection with the information
upon which the whistleblower’s application for an award is based.
Question 6b: If the whistleblower answered “yes” to question 6a, 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 the
whistleblower’s 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 G: Entitlement to Award
This section is optional. Use this section to explain the basis for the whistleblower’s
belief that the whistleblower is entitled to an award in connection with the
whistleblower’s submission of information to the Commission or to another agency in
connection with a related action. Specifically, address how the whistleblower believes the
whistleblower voluntarily provided the Commission with original information that led to
the successful enforcement of a judicial or administrative action filed by the Commission,
or a related action. Refer to §165.11 of Part 165 of the Commission’s Regulations for
further information concerning the relevant award criteria. The whistleblower may use
additional sheets, if necessary.

Section 23(c)(1)(B) of the CEA requires the Commission to consider in determining the
amount of an award the following factors: (a) the significance of the information
provided by a whistleblower to the success of the Commission action or related action;
(b) the degree of assistance provided by the whistleblower and any legal representative of
the whistleblower in the Commission action or related action; (c) the programmatic
interest of the Commission in deterring violations of the Commodity Exchange Act
(including Regulations under the Act) by making awards to whistleblowers who provide
information that leads to the successful enforcement of such laws; and (d) whether the
award otherwise enhances the Commission’s ability to enforce the Commodity Exchange
Act, protect customers, and encourage the submission of high quality information from
whistleblowers. Address these factors in the whistleblower’s response as well.
Section H: Declaration

This section must be signed by the claimant