Fill - Free fillable CFTC - Form WB-APP PDF form

UNITED STATES

COMMODITY FUTURES TRADING COMMISSION

Washington, DC 20581

OMB APPROVAL

OMB Number: 3038-0082

FORM WB-APP

APPLICATION FOR AWARD FOR ORIGINAL INFORMATION PROVIDED

PURSUANT TO SECTION 23 OF THE COMMODITY EXCHANGE ACT

A. TELL US ABOUT YOURSELF (Required for All Submissions)

1. Last Name First Name M.I. SSN Last Four Digits

2. Street Address Apartment/Unit #

City State/Province ZIP/Postal Code Country

3. Telephone Alt. Phone E-mail Address

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 Country

4. Telephone Fax E-mail Address

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.

C. TELL US ABOUT YOUR TIP OR COMPLAINT

1a. How did you submit original information to the CFTC?

Website

Mail Fax Other

1b. Date that you submitted the information (mm/dd/yyyy)

2a. Did you file a CFTC Form TCR? YES NO

2b. Form TCR Number 2c. Date that you filed your Form TCR (mm/dd/yyyy)

3. Name(s) of the individual(s) and/or entity(s) to which your tip or complaint relates

D. NOTICE OF COVERED ACTION

1. Date of relevant Notice of Covered Action (mm/dd/yyyy) 2. Notice Number

3a. Case Name 3b. Case Number

E. CLAIMS PERTAINING TO RELATED ACTIONS

1. Name of other agency or organization to which you provided your information

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

3a. Date that you provided the information (mm/dd/yyyy) 3b. Date of action by the agency or organization (mm/dd/yyyy)

4a. Case Name 4b. Case Number

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F. ELIGIBILITY REQUIREMENTS AND OTHER INFORMATION

1. Are you currently, or were you at the time that you acquired the original information that you submitted 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. Did you provide the information identified in Section C above pursuant to a cooperation agreement with the CFTC or another

agency or organization?

YES

NO

3. Before you provided the information identified in Section C above, did you (or anyone representing you) receive any request,

inquiry or demand that relates to the subject matter of your 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 identified in Section C above and upon which your application for an award is based?

YES

NO

5. Did you acquire the information that you 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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G. ENTITLEMENT TO AWARD

Explain the basis for your belief that you are entitled to an award in connection with your submission of information to the CFTC,

or to another agency or organization in a related action. Provide any additional information that you think may be relevant in light

of the criteria for determining the amount of an award set forth in Section 23 of the Commodity Exchange Act and Part 165 of the

CFTC’s regulations. Include any supporting documents in your possession or control, and use additional sheets, if necessary.

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H. CLAIMANT’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 agency or organization in connection with a related action, I knowingly and willfully

make any false, fictitious or fraudulent statements or representations, or use any false writing or document knowing that the writing

or document contains any false, fictitious or fraudulent statement or entry.

Print Name

Signature Date

I. COUNSEL CERTIFICATION

I certify that I have reviewed this form for completeness and accuracy and that the information contained herein is true, correct and

complete to the best of my knowledge, information and belief. I further certify that I have verified the identity of the whistleblower

award claimant on whose behalf this form is being submitted by viewing the claimant’s valid, unexpired government issued

identification (e.g., driver’s license, passport) and will retain an original, signed copy of this form, with Section H signed by the

claimant, in my records. I further certify that I have obtained the claimant’s non-waivable consent to provide the Commodity

Futures Trading Commission with his or her original signed Form WB-APP upon request, and that I consent to be legally obligated

to do so within seven (7) calendar days of receiving such a request from the Commodity Futures Trading Commission.

Print Name of Attorney and Law Firm, if Applicable

Signature Date

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Privacy Act Statement

This notice is given under the Privacy Act of 1974. The Privacy Act requires that the Commodity Futures

Trading Commission (CFTC) 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. The information provided will enable

the CFTC to determine the whistleblower award claimant’s eligibility for payment of an award pursuant to Section 23 of

the Commodity Exchange Act and Part 165 of the CFTC’s regulations. This information will be used to investigate

and prosecute violations of the Commodity 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.” The CFTC requests the last four digits of the claimant’s Social Security

Number for use as an individual identifier to administer and manage the whistleblower award program. Executive

Order 9397 (November 22, 1943) allows federal agencies to use the Social Security Number as an individual

identifier. Furnishing the information is voluntary. However, if an individual is providing information for the

whistleblower award program, not providing required information may result in the 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

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

information provided to the CFTC, or to another agency or organization in a related action. In order to be

deemed eligible for an award, you must meet all the requirements set forth in Section 23 of the Commodity

Exchange Act and Part 165 of the CFTC’s regulations.

 You must sign the Form WB-APP as the claimant. If you wish to submit the Form WB-APP anonymously,

you must do so through an attorney, your attorney must sign the Counsel Certification Section of the Form

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WB-APP that is submitted to the CFTC, and you must give your attorney your original signed Form WB-

APP so that it can be produced to the CFTC upon request.



During the whistleblower award claim process, your identity must be verified in a form and manner that is

acceptable to the CFTC prior to the payment of any award.

o If you are filing your claim in connection with information that you provided to the CFTC, then

your Form WB-APP, and any attachments thereto, must be received by the CFTC within ninety

(90) days of the date of the Notice of Covered Action, or the date of a final judgment in a related

action to which the claim relates.

o If you are filing your claim in connection with information that you provided to another agency or

organization in a related action, then your Form WB-APP, and any attachments thereto, must be

received by the CFTC as follows:

 If a final order imposing monetary sanctions has been entered in a related action at the

time that you submit your claim for an award in connection with a CFTC action, you

must submit your claim for an award in that related action on the same Form WB-APP

that you use for the CFTC action.

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

the time that you submit your claim for an award in connection with a CFTC action, you

must submit your claim on Form WB-APP within ninety (90) days of the issuance of a

final order imposing sanctions in the related action.

 To submit your Form WB-APP, you must print it and either 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.

Instructions for Completing Form WB-APP

General

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

Section A: Tell Us about Yourself

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

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 last name, first name, middle initial and the last four digits of your Social Security Number;

 complete address, including city, state and zip code;

 telephone number and, if available, an alternate number where you can be reached; and

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

address, especially if you are making your claim anonymously).

Section B: Your Attorney’s Information

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 about Your Tip or Complaint

Question 1a: Indicate the manner in which you submitted your original information to the CFTC.

Question 1b: Provide the date on which you submitted your original information to the CFTC.

Question 2a: State whether you filed a CFTC Form TCR.

Question 2b: If you filed a CFTC Form TCR, provide the Form’s number.

Question 2c: If you filed a CFTC Form TCR, provide the date on which you filed the Form.

Question 3: Provide the name(s) of the individual(s) and/or entity(s) to which your tip or complaint relates.

Section D: Notice of Covered Action

The process for making a claim for a whistleblower award for a CFTC action begins with the publication of

a “Notice of Covered Action” on the CFTC’s website. This Notice is published whenever a judicial or

administrative action brought by the CFTC results in the imposition of monetary sanctions exceeding $1,000,000.

The Notice is published on the CFTC’s website subsequent to the entry of a final judgment or order in the action that

by itself, or collectively with other judgments or orders previously entered in the action, exceeds the $1,000,000

threshold required for a whistleblower to be potentially eligible for an award. The CFTC will not contact

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whistleblower claimants directly as to Notices of Covered Actions; prospective claimants should monitor the CFTC

website for such Notices.

Qu

estion 1: Provide the date of the Notice of Covered Action to which this claim relates.

Question 2: Provide the notice number of the Notice of Covered Action.

Question 3a: Provide the case name referenced in the Notice of Covered Action.

Question 3b: Provide the case number referenced in the Notice of Covered Action.

Section E: Claims Pertaining to Related Actions

Question 1: Provide the name of the agency or organization to which you provided your information.

Question 2: Provide the name and contact information for your point of contact at the agency or organization,

if known.

Question 3a: Provide the date on which you provided your information to the agency or organization referenced

in Question 1 of this section.

Question 3b: Provide the date on which the agency or organization referenced in Question 1 of this section filed

the related action that was based upon the information that you provided.

Question 4a: Provide the case name of the related action.

Question 4b: Provide the case number of the related action.

Section F: 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 submitted 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.

Question 2: State whether you provided the information that you submitted to the CFTC pursuant to a

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

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Question 3: State whether you provided this information before you (or anyone representing you) received any

request, inquiry or demand that relates to the subject matter of your submission (i) from the CFTC,

(ii) in connection with an investigation, in spection 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 that you submitted to

the CFTC and upon which your application for an award is based.

Question 5: State

whether you acquired the information that you provided to the CFTC from any individual

described in Questions 1 through 4 of this section.

Question 6: If you answered yes to any of Questions 1 through 5 of this section, please provide details.

Section G: Entitlement to Award

This section is op

tional. Use this section to explain the basis for your belief that you are entitled

to an award in connection with your submission of information to the CFTC, or to another agency in

connection with a related action. Specifically, address why you believe that you voluntarily provided the

CFTC with original information that led to the successful enforcement of a judicial or administrative action

filed by the CFTC, or a related action. Refer to Section 165.9 of Part 165 of the CFTC’s regulations for

further information concerning the relevant award criteria.

Section 23(c)(1)(B) of the Commodity Exchange Act and Section 165.9(a) of Part 165 of the CFTC’s

regulations require the CFTC to consider the following factors in determining the amount of an award: (1)

the significance of the information provided by a whistleblower to the success of the CFTC action or

related action; (2) the degree of assistance provided by the whistleblower and any legal representative of

the whistleblower in the CFTC action or related action; (3) the programmatic interest of the CFTC in

deterring violations of the Commodity Exchange Act (including regulations under the Act) by making awards

to whistleblowers who provide information that leads to the successful enforcement of such laws; (4)

whether the award otherwise enhances the CFTC’s ability to enforce the Commodity Exchange Act, protect

customers, and encourage the submission of high quality information from whistleblowers; and (5) potential

adverse incentives from oversize awards. Address these factors in your response as well.

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Section H: Claimant’s Declaration

You must sign this Declaration if you are submitting this claim pursuant to the CFTC whistleblower

program and wish to be considered for an award. If you are submitting your claim anonymously, you must do so

through an attorney, and you must provide your attorney with your original signed Form WB-APP.

Section I: Counsel Certification

If you are submitting this claim pursuant to the CFTC whistleblower program anonymously, you must do

so through an attorney, and your attorney must sign the Counsel Certification Section.

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