3038-0082 FORM TCR (Tip, Complaint or Referral)

UNITED STATES
COMMODITY FUTURES TRADING COMMISSION
Washington, DC 20581

OMB APPROVAL
OMB Number:
Expires:

FORM TCR
TIP, COMPLAINT OR REFERRAL

A. TELL US ABOUT YOURSELF
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

Please be advised that pursuant to 5 C.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.

3038-0082
10/31/14

B. YOUR 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 WHO YOU ARE COMPLAINING ABOUT
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. Telephone

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. Telephone

E-mail Address

ZIP/Postal Code

Country

Internet Address

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D. TELL US ABOUT YOUR COMPLAINT
1. Occurrence Date (mm/dd/yyyy)

2. Nature of Complaint

3a. Type of Financial Product or Investment, if Applicable

3b. Name of Financial Product or Investment, if Applicable

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

5. 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.

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6. Describe how and from whom you obtained the information that supports your allegations. 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.

7. Identify with particularity any documents or other information in your submission that you believe could reasonably be expected
to reveal your identity and explain the basis for your belief that your identity would be revealed if the documents or information
were disclosed to a third party.

8a. Have you or your attorney had any prior communication(s) with the CFTC concerning this matter? YES

NO

8b. If the answer to 8a is “Yes,” please identify the CFTC staff member(s) with whom you or your attorney communicated.

9a. Have you or your attorney 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
9b. If the answer to 9a is “Yes,” please provide details. Use additional sheets, if necessary.

9c. If the answer to 9a is “Yes,” please provide the name and contact information of the point of contact at the other agency or
organization, if known.

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10a. Does this complaint relate to an entity of which you are or were an officer, director, counsel, employee, consultant or
contractor? YES
NO
10b. If the answer to Question 10a is “Yes,” have you reported this violation to your supervisor, compliance office, whistleblower
hotline, ombudsman, or any other available mechanism at the entity for reporting violations? YES
NO
10c. If the answer to Question 10b is “Yes,” please provide details. Use additional sheets, if necessary.

10d. Date on which you took the action(s) described in Question 10b (mm/dd/yyyy):

11a. Have you taken any other action regarding your complaint? YES

NO

11b. If the answer to Question 11a is “Yes,” please provide details. Use additional sheets, if necessary.

12. Provide any additional information that you think may be relevant.

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E. WHISTLEBLOWER ELIGIBILITY REQUIREMENTS AND OTHER INFORMATION
1. Are you currently, or were you at the time that you acquired the original information that you are submitting to the CFTC, a
member, officer or employee of: the CFTC; the Board of Governors of the Federal Reserve System; 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; a law enforcement organization; or a foreign
regulatory authority or law enforcement organization?
YES

NO

2. Are you providing this information pursuant to a cooperation agreement with the CFTC or another agency or organization?
YES

NO

3. Before you provided this information, did you (or anyone representing you) receive any request, inquiry or demand that relates
to the subject matter of this 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?
YES

NO

4. 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 that you are submitting to the CFTC?
YES

NO

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

NO

6. If you answered “Yes” to any of Questions 1 through 5 above, please provide details. Use additional sheets, if necessary.

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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-waivable 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 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) inform individuals of the following when asking for information. The solicitation of this
information is authorized under the Commodity Exchange Act, 7 U.S.C. § 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
CFTC’s regulations. If an individual is submitting this information for the CFTC’s whistleblower award program
pursuant to Section 23 of the Commodity Exchange Act, the information provided will be used to enable the CFTC 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 the CFTC’s 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 in Section 23 of the Commodity Exchange Act and Part 165 of the CFTC’s regulations. 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 CFTC-16, “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 Commodity Futures Trading Commission, Whistleblower
Office, Three Lafayette Centre, 1155 21st Street, NW, Washington, DC 20581.
Submission Procedures


If you are submitting information for the CFTC’s whistleblower award program, you must submit your
information using this Form TCR.



You may submit this form electronically, through the web portal found on the CFTC’s website at
http://www.cftc.gov. You may also print this form and submit it by mail to Commodity Futures Trading
Commission, Whistleblower Office, Three Lafayette Centre, 1155 21st Street, NW, Washington, DC
20581, or by facsimile to (202) 418-5975.



You have the right to submit information anonymously. However, in order to receive a whistleblower
award, you will need to be identified to select CFTC staff for a final eligibility determination, and in

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unusual circumstances, you may need to be identified publicly for trial. You should therefore provide some
means for the CFTC’s staff to contact you, such as a telephone number or an e-mail address.
Instructions for Completing Form TCR
General
All references to “you” and “your” are intended to mean the whistleblower.
Section A: Tell Us About Yourself
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 you can be reached;



your e-mail address (to facilitate communications, we strongly encourage you to provide an e-mail
address, especially if you are filing anonymously);



your preferred method of communication; and



your occupation.

Section B: Your Attorney’s Information
Complete this section only if you are represented by an attorney in this matter.
Questions 1-4: Provide the following information about your attorney:


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 Who You Are Complaining About
Question 1:

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

For Individuals: accountant, analyst, associated person, attorney, auditor, broker, commodity
trading advisor, commodity pool operator, compliance officer, employee, executing broker,

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executive officer or director, financial planner, floor broker, floor trader, trader, unknown or
other (specify).


For Entities: bank, commodity pool, commodity pool operator, commodity trading
advisor, 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 Your Complaint
Question 1:

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

Question 2:

Choose the following 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:


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));

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

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 or 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



other (analyst complaints, market maker activities, employer/employee disputes or other
(specify)).

Question 3a:

Choose the following option that you believe 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 3b:

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

Question 4:

State in detail all facts pertinent to the alleged violation. Explain why you believe the facts
described constitute a violation of the Commodity Exchange Act.

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Question 5:

Describe all supporting materials in your possession, custody or control, and the availability and
location of additional supporting materials not in your possession, custody or control.

Question 6:

Describe how you obtained the information that supports your allegations. 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.

Question 7:

Identify any documents or other information in your submission on this Form TCR that you
believe could reasonably be expected to reveal your identity. Explain the basis for your belief that
your identity would be revealed if the documents or information were disclosed to a third party.

Question 8a:

State whether you or your attorney have had any prior communication(s) with the CFTC
concerning this matter.

Question 8b:

If the answer to Question 8a is yes, identify the CFTC staff member(s) with whom you or your
attorney communicated.

Question 9a:

Indicate whether you or your attorney have provided the information you are providing to the
CFTC to any other agency or organization, or whether any other agency or organization has
requested the information or related information from you.

Question 9b:

If the answer to Question 9a is yes, provide details.

Question 9c:

If the answer to Question 9a is yes, provide the name and contact information of the point of
contact at the other agency or organization, if known.

Question 10a:

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

Question 10b:

If the answer to Question 10a is yes, state whether you have reported this violation to your
supervisor, compliance office, whistleblower hotline, ombudsman, or any other available
mechanism at the entity for reporting violations.

Question 10c:

If the answer to Question 10b is yes, provide details.

Question 10d:

Provide the date on which you took the action(s) described in Questions 10b and 10c.

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Question 11a:

Indicate whether you have taken any other action regarding your complaint, including whether you
complained to the CFTC, another regulator, a law enforcement agency, or any other agency or
organization, or initiated legal action, mediation, arbitration or any other action.

Question 11b:

If you answered yes to Question 11a, 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.

Question 12:

Provide any additional information you think may be relevant.

Section E: Whistleblower Eligibility Requirements and Other Information
Question 1:

State whether you are currently, or were at the time that you acquired the original information that
you are submitting to the CFTC, a member, officer or employee of: the CFTC; the Board of
Governors of the Federal Reserve System; 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 selfregulatory organization; a law enforcement organization; or a foreign regulatory authority or law
enforcement organization.

Question 2:

State whether you are providing the information pursuant to a cooperation agreement with the
CFTC or with another agency or organization.

Question 3:

State whether you are providing this information before you (or anyone representing you) received
any request, inquiry or demand that relates to the subject matter of this 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 you are currently a subject or target of a criminal investigation, or whether you have
been convicted of a criminal violation, in connection with the information you are submitting to
the CFTC.

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Question 5:

State whether you acquired the information you are providing 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, please provide details.

SECTION F: Whistleblower’s Declaration
You must sign this Declaration if you are submitting this information pursuant to the CFTC whistleblower
program and wish to be considered for an award. If you are submitting your information using the electronic
version of Form TCR through the CFTC’s web portal, you must check the box to agree with the declaration. If you
are submitting your information anonymously, you must still sign this Declaration (using the term “anonymous”) or
check the box as appropriate, and, if you are represented by an attorney, you must provide your attorney with the
original of this signed form, or maintain a copy for your own records. If you are not submitting your information
pursuant to the CFTC whistleblower program, you do not need to sign this Declaration or check the box.
SECTION G: Counsel Certification
If you are submitting this information pursuant to the CFTC whistleblower program and you are doing so
anonymously through an attorney, your attorney must sign the Counsel Certification Section. If your attorney is
submitting your information using the electronic version of Form TCR through the CFTC’s web portal, he/she must
check the box to agree with the certification. If you are represented in this matter but you are not submitting your
information pursuant to the CFTC whistleblower program, your attorney does not need to sign this Certification or
check the box.

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