Comparison (redline) for Form WB-APP

UNITED STATES
COMMODITY FUTURES TRADING COMMISSION
Washington, D.C.DC 20581

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3038-0082Formatted
10/31/14 Formatted

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OMB APPROVAL
OMB Number:
Expires:

FORM WB-APP
APPLICATION FOR AWARD FOR ORIGINAL INFORMATION
SUBMITTEDPROVIDED
PURSUANT TO SECTION 23 OF THE COMMODITY EXCHANGE ACT

A. APPLICANT’S INFORMATION (REQUIRED FOR ALL SUBMISSIONS)A. TELL US ABOUT
YOURSELF (Required for All Submissions)
1. Last Name:
First: Name
M.I.:
SSN Last Four Digits:
.
2. Street Address:

City:

Apartment/Unit #:#

State/Province:

3. Telephone:

Alt. Phone:

ZIP/Postal Code:

Country:

E-mail Address:

B. YOUR ATTORNEY’S INFORMATION (IF APPLICABLE – SEE INSTRUCTIONSIf Applicable
– See Instructions)
1. Attorney’s Name:
2. Firm Name:

3. Street Address:

City:

State/Province:

4. Telephone:

Fax:

Zip/Postal Code:

Country:

E-mail Address:

Please be advised that pursuant to 5 CFRC.F.R. § 1320.5(b)(2)(i), you are not required to respond to this collection of
information unless it displays a currently valid OMB control number.

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C. TIP/COMPLAINT DETAILSC. TELL US ABOUT YOUR TIP OR COMPLAINT
1b. Date that you submitted the information (mm/dd/yyyy)
1. Manner in which1a. How did you submit original
information was submitted to the CFTC
?
CFTC:

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Website
Mail
Fax
Other
2a. Did you file a CFTC Form TCR? YES

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NO

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

2c. 2b. Date that you filed your Form TCR referred to in 2a
submitted to CFTC: (mm/dd/yyyy)

3. Name2c. Subject(s) of the Tip, Complaint individual(s) and/or Referral:entity(s) to which your tip or complaint relates

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D. NOTICE OF COVERED ACTION
1. Date of relevant Notice of Covered Action to Which
Claim Relates:(mm/dd/yyyy)

2. Notice Number:

3a. Case Name:

3b. Case Number:

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

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

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

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

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4a. Case Name:

4b. Case Number:

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F. ELIGIBILITY REQUIREMENTS AND OTHER INFORMATION
1. Is the whistleblower Are you currently, or was the whistleblowerwere you at the time the whistleblowerthat you
acquired the original information the whistleblowerthat you 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
CFTC; the Board of Governors of the Federal Reserve System, the ; the Office of the Comptroller of the Currency; the Board of
Directors of the Federal Deposit Insurance Corporation,; the Director of the Office of Thrift Supervision,; the National Credit
Union Administration, Board; the Securities and Exchange Commission,; the Department of Justice; a registered entity,; a
registered futures association,; a self-regulatory organization, any; a law enforcement organization,; or a foreign regulatory

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

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authority or law enforcement organization?

YES

NO

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

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 provide3. Before you provided the information identified in Section C above before the
whistleblower, did you (or anyone representing you) receivedreceive any request, inquiry or demand that relates to the subject
matter of the whistleblower’syour 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

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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)

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6a. Is the whistleblower4. Are you currently a subject or target of a criminal investigation, or have the whistlebloweryou
been convicted of a criminal violation, in connection with the information identified in Section C above and upon which the
whistleblower’syour application for an award is based?

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5. Did you acquire the information that you provided to the CFTC from any person described in Questions 1 through 4 above?
YES

NO

6b.6. If the whistlebloweryou answered “Yes” to question 6aany of Questions 1 through 5 above, please provide details: (.
Use additional sheets, if necessary).

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G. ENTITLEMENT TO AWARD

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Explain the basis for the whistleblower’syour belief that the whistleblower isyou are entitled to an award in connection with
the whistleblower’syour submission of information to the CFTC, or to another agency or organization in a related action.
Provide any additional information the whistleblower thinksthat you think may be relevant in light of the criteria for
determining the amount of an award set forth in Section 23 of the CommoditiesCommodity Exchange Act and Part 165 of the
Commission’s Regulations thereunder: (CFTC’s regulations. Include any supporting documents in the
whistleblower’syour possession or control, and use additional sheets, if necessary).

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H. CLAIMANT’S DECLARATION

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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 agency or organization 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

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

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I. 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
award claimant on whose behalf this form is being submitted by viewing the claimant’s valid, unexpired government issued
identification (e.g., driver’s license, passport) and will retain an original, signed copy of this form, with Section H signed by the
claimant, in my records. I further certify that I have obtained the claimant’s non-waivable consent to provide the Commodity
Futures Trading Commission with his or her original signed Form WB-APP upon request, 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.
Print Name of Attorney and Law Firm, if Applicable

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 Commodity Futures
Trading Commission (CFTC or Commission) inform individuals of the following when asking for information. The

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solicitation of this information is authorized under the Commodity Exchange Act, 7 USCU.S.C. § 1 et seq. The
information provided will enable the CommissionCFTC to determine the whistleblower’swhistleblower award
claimant’s eligibility for payment of an award pursuant to Section 23 of the Commodity Exchange Act. and Part 165 of
the CFTC’s regulations. This information will be used to investigate and prosecute violations of the Commodity

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Exchange Act and Commissionthe CFTC’s regulations. This information may be disclosed to Federalfederal, 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 in Section 23
of the Commodity Exchange Act and Part 165 of the Commission’s Regulations thereunder.CFTC’s regulations.

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The information will be maintained and additional disclosures may be made in accordance with System of Records
Notices CFTC-49, “Whistleblower Records” (exempted), CFTC-10, “Investigatory Records” (exempted), and

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CFTC-16, “Enforcement Case Files.” The CommissionCFTC requests the last four digits of athe claimant’s

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Social Security Number for use as an individual identifier to administer and manage the whistleblower award
program. Executive Order 9397 (Nov.November 22, 1943) allows Federalfederal agencies to use the Social

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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

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whistleblowerindividual not being eligible for award consideration.
Questions concerning this form may be directed to the Commodity Futures Trading Commission, Attention:

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TCRWhistleblower Office, Three Lafayette Centre, 1155 21st Street, N.W.,NW, Washington, DC 20581.

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General

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Submission Procedures
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

This form shouldmust be used by persons making a claim for a whistleblower award in connection with

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information provided to the CFTC, or to another agency or organization in a related action. In order to be
deemed eligible for an award, the whistlebloweryou must meet all the requirements set forth in Section
23 of the CommoditiesCommodity Exchange Act and the rules thereunderPart 165 of the CFTC’s

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regulations.

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

The whistleblower You must sign the Form WB-APP as the claimant. If If you wish to submit the
whistleblower provided the whistleblower’s information to the CFTCForm WB-APP
anonymously, the whistlebloweryou must now disclosedo so through an attorney, your attorney must

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sign the Counsel Certification Section of the Form WB-APP that is submitted to the CFTC, and you must
give your attorney your original signed Form WB-APP so that it can be produced to the whistleblower’s

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identity on this form and CFTC upon request.


During the whistleblower’swhistleblower award claim process, your identity must be verified in a form

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and manner that is acceptable to the CFTC prior to the payment of any award.

o

If the whistleblower isyou are filing the whistleblower’syour claim in connection with

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information that the whistlebloweryou provided to the CFTC, then the whistleblower’syour
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

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to which the claim relates.

o

If the whistleblower isyou are filing the whistleblower’syour claim in connection with
information the whistleblowerthat you provided to another agency or organization in a related
action, then the whistleblower’syour Form WB-APP, and any attachments there tothereto,

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must be received by the Commodity Futures Trading CommissionCFTC as follows:

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

If a final order imposing monetary sanctions has been entered in a related action at the
time the whistleblower submits the whistleblower’sthat you submit your claim

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for an award in connection with a CommissionCFTC action, the whistlebloweryou

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must submit the whistleblower’syour claim for an award in that related action on the

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same Form WB-APP that the whistleblower usesyou use for the

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CommissionCFTC action.

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

If a final order imposing monetary sanctions in a related action has not been entered at

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the time the whistleblower submits the whistleblower’sthat you submit your

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claim for an award in connection with a CommissionCFTC action, the

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whistlebloweryou must submit the whistleblower’syour claim on Form WB-APP

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within ninety (90) days of the issuance of a final order imposing sanctions in the related
action.

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

The whistleblower must To submit the whistleblower’syour Form WB-APP, you must print it and
either submit it by mail to us in one of the following two ways:
o By mailing or delivering the signed form to the Commodity Futures Trading
Commission, Attention: TCRWhistleblower Office, Three Lafayette Centre, 1155 21st Street,

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NW, Washington, DC 20581;, or

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o By faxing the signed form by facsimile to (202) 418-5975.

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between paragraphs of the same style
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Instructions for Completing Form WB-APP
General

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underline
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All references to “you” and “your” are intended to mean the whistleblower award claimant.

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Section A: Applicant’s Information Tell Us about Yourself

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

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

First and last name, andfirst name, middle initial, and social security number and the last
four digits of your Social Security Number;

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

Completecomplete address, including city, state and zip code;

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

Telephonetelephone number and, if available, an alternate number where the whistleblower

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you can be reached; and

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

E-mail address.



your e-mail address (to facilitate communications, we strongly encourage you to provide an email
address, especially if you are making your claim anonymously).

Section B: Your Attorney’s Information. If the whistleblower is represented by an attorney in

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Complete this matter, provide the information requested. If the whistleblower is notsection

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only if you are represented by an attorney in this matter, leave this Section blank.
Provide the following information about theyour attorney representing the whistleblower

Questions 1-4:

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in this matter: :

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

Attorney’s name;



Firmattorney’s name;



Completefirm name;



complete address, including city, state and zip code;

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

Telephonetelephone number and fax number; and

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

Ee-mail address.

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Section C: Tell Us about Your Tip/ or Complaint Details

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Question 1: 1a: Indicate the manner in which the whistleblower’syou submitted your original information to

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the CFTC.
Question 1b:

Provide the date on which you submitted your original information was submitted to the CFTC.

Question 2a:

Include the

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State whether you filed a CFTC Form TCR (Tip, Complaint or Referral)

number to which this claim relates. .

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Question 2b:

Provide

If you filed a CFTC Form TCR, provide the date on which the

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whistleblower submitted the whistleblower’s information to the CFTC. Form’s
number.

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Question 2c:

If you filed a CFTC Form TCR, provide the date on which you filed the Form.

Question 3:

Provide the name(s) of the individual(s) and/or entity(s) to which the whistleblower’syour tip,

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or complaint, or referral related relates.

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Section D: Notice of Covered Action

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

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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

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to be potentially eligible for an award. The CommissionCFTC will not contact whistleblower claimants directly

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as to Notices of Covered Actions; prospective claimants should monitor the CommissionCFTC website for such

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Notices.

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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 the Notice of Covered Action.

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Question 3b:

Provide the case number referenced in the Notice of Covered Action.

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Section E: Claims Pertaining to Related Actions
Question 1:

Provide the name of the agency or organization to which the whistlebloweryou provided the

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whistleblower’syour information.
Question 2:

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Provide the name and contact information for the whistleblower’syour point of contact at the

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agency or organization, if known.
Question 3a:

Provide the date on which that the whistlebloweryou provided the whistleblower’syour

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information to the agency or organization referenced in question E1Question 1 of this section.

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Question 3b:

Provide the date on which the agency or organization referenced in question E1Question 1 of

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this section filed the related action that was based upon the information the whistleblowerthat

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you provided.

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Question 4a:

Provide the case name of the related action.

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Question 4b:

Provide the case number of the related action.

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Section F: Eligibility Requirements and Other Information

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Question 1:

State whether the whistleblower isyou are currently, or waswere at the time the

whistleblowerthat you acquired the original information that the whistlebloweryou
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
CFTC; the Board of Governors of the Federal Reserve System, the ; the Office of the Comptroller
of the Currency; the Board of Directors of the Federal Deposit Insurance Corporation,; the

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Director of the Office of Thrift Supervision,; the National Credit Union Administration, Board;

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the Securities and Exchange Commission,; the Department of Justice; a registered entity,; a

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registered futures association,; a self-regulatory organization, any; a law enforcement

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Question 2:

organization,; or a foreign regulatory authority or law enforcement organization.

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State whether the whistlebloweryou provided the information that you submitted to the CFTC

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Question 3:

pursuant to a cooperation agreement with the CFTC, or with any other agency or organization.

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State whether the whistleblower acquired theyou provided this information the

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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 whistlebloweryou (or anyone representing the whistlebloweryou) received any

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request, inquiry or demand that relates to the subject matter of the whistleblower’syour

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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

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state authority.
Question 5b:

If the whistleblower answered “yes” to questions 5a, please provide details. Use
additional sheets if necessary.

Question 6a: 4:State whether the whistleblower is theyou are currently a subject or target of a criminal

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investigation, or haswhether you have been convicted of a criminal violation, in connection with

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the information that you submitted to the CFTC and upon which the whistleblower’syour

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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

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13

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.

Question 5:

State whether you acquired the information that you provided to the CFTC from any individual
described in Questions 1 through 4 of this section.

Question 6:

If you answered yes to any of Questions 1 through 5 of this section, please provide details.
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Section G: Entitlement to Award
This section is optional. Use this section to explain the basis for the whistleblower’syour
belief that the whistleblower isyou are entitled to an award in connection with the

whistleblower’syour submission of information to the CommissionCFTC, or to another agency in

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connection with a related action. Specifically, address how the whistleblower believes the

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whistleblowerwhy you believe that you voluntarily provided the CommissionCFTC with original
information that led to the successful enforcement of a judicial or administrative action filed by the

CommissionCFTC, or a related action. Refer to §Section 165.119 of Part 165 of the Commission’s

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RegulationsCFTC’s regulations for further information concerning the relevant award criteria. The

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whistleblower may use additional sheets, if necessary.

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Section 23(c)(1)(B) of the CEA requires the CommissionCommodity Exchange Act and Section

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165.9(a) of Part 165 of the CFTC’s regulations require the CFTC to consider the following factors in
determining the amount of an award the following factors: (a: (1) the significance of the information

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14

provided by a whistleblower to the success of the CommissionCFTC action or related action; (b2) the

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degree of assistance provided by the whistleblower and any legal representative of the whistleblower in the

CommissionCFTC action or related action; (c3) the programmatic interest of the CommissionCFTC in

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deterring violations of the Commodity Exchange Act (including Regulationsregulations under the Act) by
making awards to whistleblowers who provide information that leads to the successful enforcement of such
laws; and (d(4) whether the award otherwise enhances the Commission’sCFTC’s ability to enforce the

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Commodity Exchange Act, protect customers, and encourage the submission of high quality information
from whistleblowers.; and (5) potential adverse incentives from oversize awards. Address these factors in

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the whistleblower’syour response as well.

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Section H: Claimant’s Declaration

This section must be signed by the claimantYou must sign this Declaration if you are submitting
this claim pursuant to the CFTC whistleblower program and wish to be considered for an award. If you are
submitting your claim anonymously, you must do so through an attorney, and you must provide your attorney with
your original signed Form WB-APP.
Section I: Counsel Certification
If you are submitting this claim pursuant to the CFTC whistleblower program anonymously, you must do
so through an attorney, and your attorney must sign the Counsel Certification Section.

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