Template for Updated Form TCR

OMB APPROVAL

OMB Number: 3038-0082

Expires: 10/31/14

UNITED STATES

COMMODITY FUTURES TRADING COMMISSION

Washington, DC 20581

FORM TCR

TIP, COMPLAINT OR REFERRAL

See attached Privacy Act Statement, Submission Procedures and Completion Instructions Below.

A. TELL US ABOUT YOURSELF
COMPLAINANT 1:
1. Last Name		2. First Name			3. M.I.
4. Street Address				5. Apartment/Unit #
6. City	7. State/Province		8. ZIP/Postal Code	9. Country
10. Telephone	11. Alt. Phone		12. E-mail Address	13. Preferred Method of Communication
14. Occupation
COMPLAINANT 2:
1. Last Name		2. First Name			3. M.I.
4. Street Address				5. Apartment/Unit #
6. City	7. State/Province		8. ZIP/Postal Code	9. Country
10. Telephone	11. Alt. Phone		12. E-mail Address	13. Preferred Method of Communication
14. Occupation

B. YOUR ATTORNEY’S INFORMATION (If Applicable – See Instructions)
1. Attorney’s Name
2. Firm Name
3. Street Address
4. City	5. State/Province	6. ZIP/Postal Code	7. Country
8. Telephone	9. Fax	10. E-mail Address

C. TELL US who you are COMPLAINING ABOUT
Individual / Entity 1:
1. Type: Individual Entity	2. If an individual, specify profession. If an entity, specify type.
3. Name
4. Street Address				5. Apartment/Unit #
6. City	7. State/Province	8. ZIP/Postal Code		9. Country
10. Telephone	11. E-mail Address		12. Internet Address
13. If you are complaining about a firm or individual that has custody or control of your investments, have you had difficulty contacting that entity or individual? [] Yes [] No [] Unknown
14. Are you, or were you, associated with the individual or firm when the alleged conduct occurred? [] Yes [] No [] Unknown If yes, describe how you are, or were, associated with the individual or firm you are complaining about? Text Box
15. What was the initial form of contact between you and the person against whom you are filing this complaint? [] Telephone [] TV Advertisement [] Radio Advertisement [] Internet Advertisement [] E-Mail [] U.S. Postal Service [] Event (seminar, free lunch, ext.) [] Other If other, please describe: Text Box

Individual / Entity 2:
1. Type: Individual Entity	2. If an individual, specify profession. If an entity, specify type.
3. Name
4. Street Address				5. Apartment/Unit #
6. City	7. State/Province	8. ZIP/Postal Code		9. Country
10. Telephone	11. E-mail Address		12. Internet Address
13. If you are complaining about a firm or individual that has custody or control of your investments, have you had difficulty contacting that entity or individual? [] Yes [] No [] Unknown
14. Are you, or were you, associated with the individual or firm when the alleged conduct occurred? [] Yes [] No [] Unknown If yes, describe how you are, or were, associated with the individual or firm you are complaining about? Text Box
15. What was the initial form of contact between you and the person against whom you are filing this complaint? [] Telephone [] TV Advertisement [] Radio Advertisement [] Internet Advertisement [] E-Mail [] U.S. Postal Service [] Event (seminar, free lunch, ext.) [] Other If other, please describe: Text Box

D. TELL US ABOUT YOUR COMPLAINT
1. Occurrence Date (mm/dd//yyyy):	2. Is the conduct on-going? [] Yes [] No [] Don’t Know
3. Please select the option(s) that best describes your complaint. [] Fraudulent representations that persuaded you to trade futures, options, swaps, forex, or leveraged transactions [] Some type of cheating or fraud that occurred after you had deposited funds to trade futures, options, swaps, forex, retail commodity, or leveraged transactions (for example, if someone used the funds you deposited to pay off someone else or you have asked for the return of your funds and have been refused). [] Someone or some firm that should be registered under the Commodity Exchange Act, but is not. [] Disruptive or manipulative trading activity in the futures, options or swaps markets. [] The trading of futures options, or swaps based upon confidential information by someone not allowed to use such information. Text Box [] If your complaint does not fit into any of the above-described categories please describe below.
4. Select the type of product/instrument: [] A futures contract, including a single stock futures contract, a narrow based or broad based security future contract. [] An option on a futures contract, an option on a commodity, BUT NOT an option on a security or a basket of securities. [] A swap, including a mixed swap BUT NOT a swap based on a single security or based on a narrow (i.e., nine or less) index of securities. [] A cash (or physical) contract traded in interstate commerce? [] A foreign currency transaction. If a foreign currency transaction: Are you an individual that trades or invests more than $10,000,000 on a discretionary basis? [] Yes [] No Are you an individual that trades or invests more than $5,000,000 and enters into the foreign currency agreement to manage the risk associated with some other asset or liability? [] Yes [] No [] A commodity transaction entered into or offered on a leveraged or margined basis, or financed by the offeror, the counterparty, or someone acting in concert with the offeror or counterparty. If yes: Are you an individual that trades or invests more than $10,000,000 on a discretionary basis? [] Yes [] No Are you an individual that trades or invests more than $5,000,000 and enters into the foreign currency agreement to manage the risk associated with some other asset or liability? [] Yes [] No [] Other If other, please describe: Text Box
5. If applicable, what is the name of product/investment? Text Box
6. Have you suffered a monetary loss? [] Yes [] No If yes, describe how much. Text Box
7. Has the individual or firm who engaged in the conduct acknowledged their fault? [] Yes [] No
8. Have you or anyone else taken any action against the firm or person who engaged in the alleged conduct? [] Yes [] No If yes, select the appropriate category: Prior complaint to the CFTC. [] Complaint to another regulator. [] A state or federal criminal law enforcement entity. [] A legal action filed against the person or firm in a court of law. [] Additional comments based on above selection (e.g., Who, When, Contact, To whom made, Case Number, Court). Text Box

9. 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. If necessary, please use additional sheets.

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10. Describe all supporting materials in your possession and the availability and location of any additional supporting materials not in your possession. If necessary, please use additional sheets.

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E. WHISTLEBLOWER Program

1. 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.

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2. 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.

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3. Have you or your attorney had any prior communication(s) with the CFTC concerning this matter? [] Yes [] No

If “Yes,” please identify the CFTC staff member(s) with whom you or your attorney communicated:

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4. 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

If “Yes,” please provide details. Use additional sheets, if necessary.

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If “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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5. Does this complaint relate to an entity of which you are or were an officer, director, counsel, employee, consultant or contractor? [] Yes [] No

If “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

If “Yes,” please provide details including the date you took the action(s). Use additional sheets, if necessary.

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6. Have you taken any other action regarding your complaint? [] Yes [] No

If “Yes,” please provide details. Use additional sheets, if necessary.

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

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8. May the CFTC have your consent to share your identifying information with other governmental authorities? [] Yes [] No

Other governmental authorities may include: The Department of Justice; an appropriate department or agency of the Federal Government; a state attorney general; any appropriate state department or agency; or a foreign governmental authority.

As a whistleblower, you have confidentiality protections and we may only reveal your identity under certain conditions, including with your consent, as enumerated in 17 C.F.R. § 165.4.

You may choose not to consent. If you do not consent, we will maintain your identity as confidential as required by 17 C.F.R. § 165.4.

F. 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

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

G. 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

H. 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

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.