OMB No. 3038-0009
Commodity Futures Trading Commission
Identification of "Special Accounts"
For Administrative Use Only
Trader Code: Firm Code:
NOTICE: Failure to file a report required by the Commodity Exchange Act and the regulations thereunder, or the
filing of a false or fraudulent report, may be a basis for administrative action under 7 U.S.C. Section 9, and may
be punishable by fine or imprisonment, or both, under 7 U.S.C. Section 13 or 18 U.S.C. Section 1001.
INSTRUCTIONS TO FUTURES COMMISSION MERCHANTS, CLEARING MEMBERS, AND FOREIGN BROKERS
Assign a reporting number to each special account when it is reportable for the first time in futures or options. If
an account has been assigned a number for reporting in futures (options), use the same number for reporting
options (futures). Such reporting number must not be changed or assigned to any other special account without
prior approval of the Commodity Futures Trading Commission. For a futures and/or option account, transmit the
form to the Commission.
PLEASE TYPE OR PRINT
1. Check one of "a," "b," or "c" for the special account and give identifying information as directed below:
a. House omnibus or Customer omnibus account of a futures commission merchant, clearing member, or foreign broker.
Report the information in "d" below for that firm. In addition, complete items 6 through 11.
Account(s) owned and controlled by the same person or legal entity, such as a corporation or partnership (or controlled by
an employee or officer of the entity). Report the information in "d" below for the person or other legal entity who owns and
controls the account(s). In addition, complete items 2 and 4 through 11.
Account(s) controlled by an advisor or legal entity who is independent of the account owner. Report the information in "d"
below for the advisor or legal entity controlling the special account. In addition, complete items 3 through 11.
d. Name: Reporting Number:
If Individual, Last, First, Middle Initial
Street: Business Phone:
City: State/Country: Zip/Postal Code:
If Individual, Employer Job Title:
If "b" or "c" is checked, is the above-identified person or legal entity registered as a:
Commodity trading advisor Yes No
Securities investment advisor
If this special account is reported in the name of a business, such as a corporation, give the name of an officer or employee
Name: Job Title:
Last, First, Middle Initial
2. If item 1.b is checked, complete the following:
a. Check as many as apply to the legal entity identified in 1.d above.
Individual Trust Partnership Joint
Sole Proprietorship Corporation Limited Liability Corporation
b. Principal business or occupation:
CFTC Form 102 (07/01)
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