Form TCR & Instructions

OMB Collection Number

3038-0082

UNITED STATES

COMMODITY FUTURES TRADING COMMISSION

Washington, DC 20581

FORM TCR

TIP, COMPLAINT OR REFERRAL

See attached 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, retail commodity, 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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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 (as defined in 3(a) of the Securities Exchange Act of 1934 (15 U.S.C. 78c(a)); 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 (as defined in 3(a) of the Securities Exchange Act of 1934 (15 U.S.C. 78c(a)); 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. PRIVACY NOTICE AND WHISTLEBLOWER’S DECLARATION
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. This form and related information will be processed in the United States of America, the location of the CFTC. 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. The CFTC may disclose this information when required to be disclosed to a defendant or respondent in connection with a public proceeding instituted by the Commission. In addition, if the Commission determines such disclosure is necessary or appropriate to accomplish the purposes of the CEA and to protect customers, the Commission may provide such information to the Department of Justice; an appropriate department or agency of the Federal Government; a state attorney general; any appropriate department or agency of a state; a registered entity, registered futures association, or self-regulatory organization (as defined in Section 3(a) of the Securities Exchange Act of 1934 (15 U.S.C. 78c(a)); or a foreign futures authority. Those entities are subject to the same confidentiality requirements as the Commission. The Commission also may disclose such information in accordance with Privacy Act of 1974 System of Records Notices CFTC-49, “Whistleblower Records” (exempted), CFTC-10, “Investigatory Records” (exempted), and CFTC-16, “Enforcement Case Files,” (available on the CFTC Privacy Program web page, www.cftc.gov/Transparency/PrivacyOffice) exercised in accordance with the confidentiality provisions in the CEA and 17 C.F.R. § 165.4. Furnishing information on or through this form 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. Also, you may choose to submit this form anonymously, but in order to receive a whistleblower award, you would need to be identified to select CFTC staff for a final eligibility determination, and in unusual circumstances, you may need to be identified publicly for trial. [See instructions for further information.] By signing this Declaration, I am agreeing to the collection, processing, use, and disclosure of my personally identifiable information as stated herein. 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 G 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

Submission Procedures

Questions concerning this form may be directed to Commodity Futures Trading Commission, Whistleblower Office, Three Lafayette Centre, 1155 21st Street, NW, Washington, DC 20581.

• 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.whistleblower.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. If you do not submit anonymously, please note that the CFTC is required by law to maintain the confidentiality of any information which could reasonably identify you, and will only reveal such information in limited and specifically-defined circumstances. See 7 U.S.C. § 26(h)(2); 17 C.F.R. § 165.4. 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 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 complainant.

Section A: Tell Us About Yourself

Questions 1-14: 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 1-10: 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 1-2: 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, 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 3-12: 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.

Questions 13: If the firm or individual you are complaining about has custody or control of your investment, identify whether you have had difficulty contacting that firm or individual.

Question 14: Identify if you are, or were, associated with the individual or firm you are complaining about. If yes, describe how you are, or were, associated with the individual or firm you are complaining about.

Question 15: Identify the initial form of contact between you and the person against whom you are filing this complaint.

Section D: Tell Us About Your Complaint

Question 1: State the date (mm/dd/yyyy) that the alleged conduct occurred or began.

Question 2: Identify if the conduct is on-going.

Question 3: Choose the 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.

Question 4: Select the type of product or instrument you are complaining about.

Question 5: If applicable, please name the product or instrument. If yes, please describe.

Question 6: Identify whether you have suffered a monetary loss. If yes, please describe.

Question 7: Identify if the individual or firm you are complaining about acknowledged their fault.

Question 8: 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.

If you answered yes, 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 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.

Question 10: Describe all supporting materials in your possession and the availability and location of any additional supporting materials not in your possession.

Section E: Whistleblower Program

Question 1: 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 2: 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 3: State whether you or your attorney have had any prior communication(s) with the CFTC concerning this matter.

If you answered “yes”, identify the CFTC staff member(s) with whom you or your attorney communicated.

Question 4: 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.

If you answered “yes”, provide details and the name and contact information of the point of contact at the other agency or organization, if known.

Question 5: 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.

If you answered “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. Please provide details, including the date on which you took the action.

Question 6: 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.

If you answered “yes”, 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 7: Provide any additional information you think may be relevant.

Section F: 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 self-regulatory organization (as defined in 3(a) of the Securities Exchange Act of 1934 (15 U.S.C. 78c(a));; 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 (as defined in 3(a) of the Securities Exchange Act of 1934 (15 U.S.C. 78c(a));, 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.

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 G: Privacy Notice and 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.

SECTION H: 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.

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.