Form SEC2850 Form TCR

Implementing The Whistleblower Provisions of Section 21F of the Securities Exchange Act of 1934 Form WB-APP and Form TCR

formtcr

Form TCR- Retain Counsel

OMB: 3235-0686

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OMB APPROVAL

UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
Washington, DC 20549

OMB Number: . . .. .. 3235 0686
Expires:
October 31, 2018
Estimated average burden
hours per response
1

FORM TCR
TIP, COMPLAINT OR REFERRAL
A.

INFORMATION ABOUT YOU

COMPLAINANT 1:
1. Last Name

M.I.

First
Apartment/
Unit #

2. Street Address

City

State/
Province

3. Telephone

Alt. Phone

4. Occupation

ZIP/
Postal Code

Country

E-mail Address
Preferred
method of
communication

COMPLAINANT 2:

Apartment/
Unit #

2. Street Address

City

State/
Province

3. Telephone

Alt. Phone

4. Occupation

B.

M.I.

First

1. Last Name

ZIP/
Postal Code

Country

E-mail Address
Preferred
method of
communication

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

SEC 2850 (8/11)

Country

C.

TELL US ABOUT THE INDIVIDUAL OR ENTITY YOU HAVE A COMPLAINT AGAINST
If an individual, specify profession:

INDIVIDUAL/ENTITY 1:
1. Type:

Individual

If an entity, specify type:

Entity

2. Name
Apartment/
Unit #

3. Street Address

City

State/
Province

4. Phone

E-mail Address

INDIVIDUAL/ENTITY 2:

If an individual, specify profession:

1. Type:

Individual

ZIP/
Postal Code

Country

Internet Address

If an entity, specify type:

Entity

2. Name
Apartment/
Unit #
3. Street Address

E-mail Address

4. Phone

D.

ZIP/
Postal Code

State/
Province

City

Country

Internet Address

TELL US ABOUT YOUR COMPLAINT

1. Occurrence Date (mm/dd/yyyy):

/

/

2. Nature of complaint:

3a. Has the complainant or counsel had any prior communication(s) with the SEC concerning this matter?

YES

NO

3b. If the answer to 3a is “Yes,” name of SEC staff member with whom the complainant or counsel communicated
4a. Has the complainant or counsel 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
4b. If the answer to 4a is “Yes,” please provide details. Use additional sheets if necessary.

4c. Name and contact information for point of contact at agency or organization, if known

5a. Does this complaint relate to an entity of which the complainant is or was an officer, director, counsel, employee, consultant or contractor?
YES
NO
5b. If the answer to question 5a is “Yes,” has the complainant reported this violation to his or her supervisor, compliance office, whistleblower hotline,
ombudsman, or any other available mechanism at the entity for reporting violations?
YES
NO
5c. If the answer to question 5b is “Yes,” please provide details. Use additional sheets if necessary.

5d. Date on which the complainant took the action(s) described in question 5b (mm/dd/yyyy):

6a. Has the complainant taken any other action regarding your complaint?

/

/

YES

NO

YES

NO

6b. If the answer to question 6a is “Yes,” please provide details. Use additional sheets if necessary.

7a. Does your complaint relate to a residential mortgage-backed security?
7b. Type of security or investment, if relevant

7c. Name of issuer or security, if relevant

7d. Security/Ticker Symbol or CUSIP no.

8. State in detail all facts pertinent to the alleged violation. Explain why the complainant believes the acts described constitute a violation of the federal
securities laws. Use additional sheets if necessary.

9. Describe all supporting materials in the complainant’s possession and the availability and location of any additional supporting materials not in
complainant’s possession. Use additional sheets, if necessary.

10. Describe how and from whom the complainant obtained the information that supports this claim. 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. Attach additional sheets if necessary.

11. 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 were disclosed to a third party.

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

E.

ELIGIBILITY REQUIREMENTS AND OTHER INFORMATION

1. Are you, or were you at the time you acquired the original information you are submitting to us, a member, officer or employee of the Department of
Justice, the Securities and Exchange Commission, the Comptroller of the Currency, the Board of Governors of the Federal Reserve System, the
Federal Deposit Insurance Corporation, the Office of Thrift Supervision; the Public Company Accounting Oversight Board; any law enforcement
organization; or any national securities exchange, registered securities association, registered clearing agency, or the Municipal Securities
Rulemaking Board?
YES
NO
2. Are you, or were you at the time you acquired the original information you are submitting to us, a member, officer or employee of a foreign
government, any political subdivision, department, agency, or instrumentality of a foreign government, or any other foreign financial regulatory authority
as that term is defined in Section 3(a)(52) of the Securities Exchange Act of 1934 (15 U.S.C. §78c(a)(52))?
YES
NO
3. Did you acquire the information being provided to us through the performance of an engagement required under the federal securities laws by an
independent public accountant?
YES
NO
4. Are you providing this information pursuant to a cooperation agreement with the SEC or another agency or organization?
YES
NO
5. Are you a spouse, parent, child, or sibling of a member or employee of the SEC, or do you reside in the same household as a member or employee
of the SEC?
YES
NO
6. Did you acquire the information being provided to us from any person described in questions 1 through 5?
YES
NO
7. Have you or anyone representing you received any request, inquiry or demand that relates to the subject matter of your submission (i) from the SEC,
(ii) in connection with an investigation, inspection or examination by the Public Company Accounting Oversight Board, or any self-regulatory
organization; or (iii) in connection with an investigation by the Congress, any other authority of the federal government, or a state Attorney General or
securities regulatory authority?
YES
NO
8. 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
you are submitting to the SEC?
YES
NO
9. If you answered “yes” to any of the questions 1 through 8, use this space to provide additional details relating to your responses. Use additional
sheets if necessary.

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 SEC, 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 (If Applicable—See Instructions)
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 nonwaiveable consent to provide the Commission with his or her original signed Form TCR upon request in the event that the 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 7 calendar days of receiving such a request from the Commission.

Signature

Date

Privacy Act Statement

This notice is given under the Privacy Act of 1974. This form may be used by anyone wishing to provide
the SEC with information concerning a possible violation of the federal securities laws. We are authorized
to request information from you by various laws: Sections 19 and 20 of the Securities Act of 1933,
Sections 21 and 21F of the Securities Exchange Act of 1934, Section 321 of the Trust Indenture Act of
1939, Section 42 of the Investment Company Act of 1940, Section 209 of the Investment Advisers Act of
1940 and Title 17 of the Code of Federal Regulations, Section 202.5.
Our principal purpose in requesting information is to gather facts in order to determine whether any
person has violated, is violating, or is about to violate any provision of the federal securities laws or rules
for which we have enforcement authority. Facts developed may, however, constitute violations of other
laws or rules. Further, if you are submitting information for the SEC’s whistleblower award program
pursuant to Section 21F of the Securities Exchange Act of 1934 (Exchange Act), the information provided
will be used in connection with our evaluation of your or your client’s eligibility and other factors relevant
to our determination of whether to pay an award to you or your client.
The information provided may be used by SEC personnel for purposes of investigating possible violations
of, or to conduct investigations authorized by, the federal securities law; in proceedings in which the
federal securities laws are in issue or the SEC is a party; to coordinate law enforcement activities
between the SEC and other federal, state, local or foreign law enforcement agencies, securities self
regulatory organizations, and foreign securities authorities; and pursuant to other routine uses as
described in SEC-42 “Enforcement Files.”

Furnishing the information requested herein is voluntary. However, a decision not provide any of the
requested information, or failure to provide complete information, may affect our evaluation of your
submission. Further, if you are submitting this information for the SEC whistleblower program and you do
not execute the Whistleblower Declaration or, if you are submitting information anonymously, identify the
attorney representing you in this matter, you may not be considered for an award.

Questions concerning this form maybe directed to the SEC Office of the Whistleblower, 100 F Street, NE,
Washington, DC 20549, Tel. (202) 551-4790, Fax (703) 813-9322.

Submission Procedures
x

After manually completing this Form TCR, please send it by mail or delivery to the SEC Office of
the Whistleblower, 100 F Street, NE, Washington, DC 20549, or by facsimile to (703) 813-9322.

x

You have the right to submit information anonymously. If you are submitting anonymously and
you want to be considered for a whistleblower award, however, you must (1) be represented by
an attorney in this matter and (2) complete Sections B and G of this form. If you are not
submitting anonymously, you may, but are not required to, have an attorney. If you are not
represented by an attorney in this matter, you may leave Sections B and G blank.

x

If you are submitting information for the SEC’s whistleblower award program, you must
submit your information either using this Form TCR or electronically through the SEC’s
Tips, Complaints and Referrals Portal, available on the SEC web site at

https://denebleo.sec.gov/TCRExternal/index.xhtml.
Instructions for Completing Form TCR:

Section A: Information about You
Questions 1-4: Please provide the following information about yourself:
x

Last name, first name, and middle initial

x

Complete address, including city, state and zip code

x

Telephone number and, if available, an alternate number where you can be reached

x

Your e-mail address (to facilitate communications, we strongly encourage you to provide your
email address),

x

Your preferred method of communication; and

x

Your occupation

For more than two complainants, use additional sheets as necessary to provide the required information
for each complainant.

Section B: Information about Your Attorney. Complete this section only if you are represented by
an attorney in this matter. You must be represented by an attorney, and this section must be
completed, if you are submitting your information anonymously and you want to be considered
for the SEC’s whistleblower award program.

Questions 1-4: Provide the following information about the attorney representing you in this matter:
x

Attorney’s name

x

Firm name

x

Complete address, including city, state and zip code

x

Telephone number and fax number, and

x

E-mail address

Section C: Tell Us about the Individual and/or Entity You Have a Complaint Against. If your
complaint relates to more than two individuals and/or entities, you may attach additional sheets.

Question 1:

Choose one of the following that best describes the individual or entity to which your
complaint relates:

x

For Individuals: accountant, analyst, attorney, auditor, broker, compliance officer,
employee, executive officer or director, financial planner, fund manager, investment
advisor representative, stock promoter, trustee, unknown, or other (specify).

x

For Entity: bank, broker-dealer, clearing agency, day trading firm, exchange, Financial
Industry Regulatory Authority, insurance company, investment advisor, investment advisor
representative, investment company, Individual Retirement Account or 401(k)
custodian/administrator, market maker, municipal securities dealers, mutual fund,
newsletter company/investment publication company, on-line trading firm, private fund
company (including hedge fund, private equity fund, venture capital fund, or real estate

fund), private/closely held company, publicly held company, transfer agent/paying
agent/registrar, underwriter, unknown, or other (specify).

Questions 2-4: For each subject, provide the following information, if known:
x

Full name

x

Complete address, including city, state and zip code

x

Telephone number,

x

E-mail address, and

x

Internet address, if applicable

Section D: Tell Us about Your Complaint
Question 1:

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

Question 2:

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. Use additional
sheets if necessary.

x

Theft/misappropriation (advance fee fraud; lost or stolen securities; hacking of account)

x

Misrepresentation/omission (false/misleading marketing/sales literature; inaccurate,
misleading or non-disclosure by Broker-Dealer, Investment Adviser and Associated
Person; false/material misstatements in firm research that were basis of transaction)

x

Offering fraud (Ponzi/pyramid scheme; other offering fraud)

x

Registration violations (unregistered securities offering)

x

Trading (after hours trading; algorithmic trading; front-running; insider trading,
manipulation of securities/prices; market timing; inaccurate quotes/pricing information;
program trading; short selling; trading suspensions; volatility)

x

Fees/mark-ups/commissions (excessive or unnecessary administrative fees; excessive
commissions or sales fees; failure to disclose fees; insufficient notice of change in fees;
negotiated fee problems; excessive mark-ups/markdowns; excessive or otherwise
improper spreads)

x

Corporate disclosure/reporting/other issuer matter (audit; corporate governance; conflicts
of interest by management; executive compensation; failure to notify shareholders of
corporate events; false/misleading financial statements, offering documents, press
releases, proxy materials; failure to file reports; financial fraud; Foreign Corrupt Practices
Act violations; going private transactions; mergers and acquisitions; restrictive legends,

including 144 issues; reverse stock splits; selective disclosure – Regulation FD, 17 CFR
243; shareholder proposals; stock options for employees; stock splits; tender offers)
x

Sales and advisory practices (background information on past violations/integrity; breach
of fiduciary duty/responsibility (IA); failure to disclose breakpoints; churning/excessive
trading; cold calling; conflict of interest; abuse of authority in discretionary trading; failure
to respond to investor; guarantee against loss/promise to buy back shares; high pressure
sales techniques; instructions by client not followed; investment objectives not followed;
margin; poor investment advice; Regulation E (Electronic Transfer Act); Regulation S-P,
17 CFR 248, (privacy issues); solicitation methods (non-cold calling; seminars); suitability;
unauthorized transactions)

x

Operational (bond call; bond default; difficulty buying/selling securities;
confirmations/statements; proxy materials/prospectus; delivery of funds/proceeds;
dividend and interest problems; exchanges/switches of mutual funds with fund family;
margin (illegal extension of margin credit, Regulation T restrictions, unauthorized margin
transactions); online issues (trading system operation); settlement (including T+1 or T=3
concerns); stock certificates; spam; tax reporting problems; titling securities (difficulty
titling ownership); trade execution.

x

Customer accounts (abandoned or inactive accounts; account administration and
processing; identity theft affecting account; IPOs: problems with IPO allocation or
eligibility; inaccurate valuation of Net Asset Value; transfer of account)

x

Comments/complaints about SEC, Self-Regulatory Organization, and Securities Investor
Protection Corporation processes & programs (arbitration: bias by arbitrators/forum, failure
to pay/comply with award, mandatory arbitration requirements, procedural problems or
delays; SEC: complaints about enforcement actions, complaints about rulemaking, failure
to act; Self-Regulatory Organization: failure to act; Investor Protection: inadequacy of laws
or rules; SIPC: customer protection, proceedings and Broker-Dealer liquidations;

x

Other (analyst complaints; market maker activities; employer/employee disputes; specify
other).

Question 3a:

State whether you or your counsel have had any prior communications with the SEC
concerning this matter.

Question 3b:

If the answer to question 3a is yes, provide the name of the SEC staff member with whom
you or your counsel communicated.

Question 4a:

Indicate whether you or your counsel have provided the information you are providing to
the SEC to any other agency or organization.

Question 4b:

If the answer to question 4a is yes, provide details.

Question 4c:

Provide the name and contact information of the point of contact at the other agency or
organization, if known.

Question 5a:

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 5b:

If the answer to question 5a 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 5c:

If the answer to question 5b is yes, provide details.

Question 5d:

Provide the date on which you took the actions described in questions 5a and 5b..

Question 6a:

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

Question 6b:

If you answered yes to question 6a, 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. Use additional
sheets if necessary.

Question 7a:

Check the appropriate box regarding whether your complaint relates to residential
mortgage-backed securities.

Question 7b:

List the following options that you believe best describes the type of security or
investment at issue, if applicable:

x

1031 exchanges

x

529 plans

x

American Depositary Receipts

x

Annuities (equity-indexed annuities, fixed annuities, variable annuities)

x

Asset-backed securities

x

Auction rate securities

x

Banking products (including credit cards)

x

Certificates of deposit (CDs)

x

Closed-end funds

x

Coins and precious metals (gold, silver, etc.)

x

Collateralized mortgage obligations (CMOs)

x

Commercial paper

x

Commodities (currency transactions, futures, stock index options)

x

Convertible securities

x

Debt (corporate, lower-rated or “junk”, municipal)

x

Equities (exchange-traded, foreign, Over-the-Counter, unregistered, linked notes)
Exchange Traded Funds

x

Franchises or business ventures

x

Hedge funds

x

Insurance contracts (not annuities)

x

Money-market funds

x

Mortgage-backed securities (mortgages, reverse mortgages)

x

Mutual funds

x

Options (commodity options, index options)

x

Partnerships

x

Preferred shares

x

Prime bank securities/high yield programs

x

Promissory notes

x

Real estate (real estate investment trusts (REITs))

x

Retirement plans ( 401(k), IRAs)

x

Rights and warrants

x

Structured note products

x

Subprime issues

x

Treasury securities

x

U.S. government agency securities

x

Unit investment trusts (UIT)

x

Viaticals and life settlements

x

Wrap accounts

x

Separately Managed Accounts (SMAs)

x

Unknown

x

Other (specify)

Question 7c:

Provide the name of the issuer or security, if applicable.

Question 7d:

Provide the ticker symbol or CUSIP number of the security, if applicable.

Question 8:

State in detail all the facts pertinent to the alleged violation. Explain why you believe the
facts described constitute a violation of the federal securities laws. Attach additional
sheets if necessary.

Question 9:

Describe all supporting materials in your possession and the availability and location of
additional supporting materials not in your possession. Attach additional sheets if
necessary.

Question 10:

Describe how you obtained the information that supports your allegation. 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. Attach additional sheets if necessary.

Question 11:

You may use this space to identify any documents or other information in your
submission 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 12:

Provide any additional information you think may be relevant.

Section E: Eligibility Requirements
Question 1:

State whether you are currently, or were at the time you acquired the original information
that you are submitting to the SEC, a member, officer, or employee of the Department of
Justice; the Securities and Exchange Commission; the Comptroller of the Currency, the
Board of Governors of the Federal Reserve System, the Federal Deposit Insurance
Corporation, the Office of Thrift Supervision; the Public Company Accounting Oversight
Board; any law enforcement organization; or any national securities exchange, registered
securities association, registered clearing agency, the Municipal Securities Rulemaking
Board

Question 2:

State whether you are, or were you at the time you acquired the original information you
are submitting to the SEC, a member, officer or employee of a foreign government, any
political subdivision, department, agency, or instrumentality of a foreign government, or
any other foreign financial regulatory authority as that term is defined in Section 3(a)(52)
of the Securities Exchange Act of 1934.
x

Section 3(a)(52) of the Exchange Act (15 U.S.C. §78c(a)(52)) currently
defines ‘‘foreign financial regulatory authority’’ as “any (A) foreign securities
authority, (B) other governmental body or foreign equivalent of a self-

regulatory organization empowered by a foreign government to administer
or enforce its laws relating to the regulation of fiduciaries, trusts,
commercial lending, insurance, trading in contracts of sale of a commodity
for future delivery, or other instruments traded on or subject to the rules of
a contract market, board of trade, or foreign equivalent, or other financial
activities, or (C) membership organization a function of which is to regulate
participation of its members in activities listed above.”
Question 3:

State whether you acquired the information you are providing to the SEC through the
performance of an engagement required under the securities laws by an independent
public accountant.

Question 4:

State whether you are providing the information pursuant to a cooperation agreement
with the SEC or with any other agency or organization.

Question 5:

State whether you are a spouse, parent, child or sibling of a member or employee of the
SEC, or whether you reside in the same household as a member or employee of the
SEC.

Question 6:

State whether you acquired the information you are providing to the SEC from any
individual described in Questions 1 through 5 of this Section.

Question 7:

State whether you or anyone representing you has received any request, inquiry or
demand that relates to the subject matter of your submission in connection with: (i) an
investigation, inspection or examination by the SEC, the Public Company Accounting
Oversight Board, or any self-regulatory organization; or (ii) an investigation by Congress,
or any other authority of the federal government, or a state Attorney General or securities
regulatory authority?

Question 8:

State whether you are the subject or target of a criminal investigation or have been
convicted of a criminal violation in connection with the information you are submitting to
the SEC.

Question 9:

If you answered “Yes” to any of questions 1 through 8, provide additional details relating
to your response.

SECTION F: Whistleblower’s Declaration.
You must sign this Declaration if you are submitting this information pursuant to the SEC
whistleblower program and wish to be considered for an award. If you are submitting your
information anonymously, you must still sign this Declaration, and you must provide your
attorney with the original of this signed form.
If you are not submitting your information pursuant to the SEC whistleblower program, you do not
need to sign this Declaration.

SECTION G: COUNSEL CERTIFICATION
If you are submitting this information pursuant to the SEC whistleblower program and are
doing so anonymously, your attorney must sign the Counsel Certification section.
If you are represented in this matter but you are not submitting your information pursuant to the
SEC whistleblower program, your attorney does not need to sign the Counsel Certification Section.


File Typeapplication/pdf
File TitleForm TCR - Implementation of the Whistleblower Provisions of Section 21F of the Securities Exchange Act of 1934
SubjectDate: 2012-05-24
AuthorU.S. Securities and Exchange Commission
File Modified2018-01-05
File Created2018-01-05

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