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1. Attorney’s Name _________________________________________________ Country ________________________

2. Firm Name ______________________________________________________________________________________

3. Street Address __________________________________________________________________________________

City ________________ State/ Province ________________ ZIP Code ____________ Fax ___________________

4. Primary Phone ___________________ E-mail Address _________________________________________________

B. ATTORNEY’S INFORMATION (IF APPLICABLE – SEE INSTRUCTIONS)

1. Manner in which original information was submitted to SEC SEC website Mail Fax Other 

2a. Tip, Complaint or Referral number___________ 2b. Date TCR referred to in 2a submitted to SEC_____________

2c. Subject(s) of the Tip, Complaint or Referral: _________________________________________________________

C. TIP/COMPLAINT DETAILS

UNITED STATES 

SECURITIES AND EXCHANGE COMMISSION

WASHINGTON, DC 20549

FORM WB-APP

APPLICATION FOR AWARD FOR ORIGINAL INFORMATION SUBMITTED

PURSUANT TO SECTION 21F OF THE SECURITIES EXCHANGE ACT OF 1934

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1. Last Name ___________________________ First _______________________ M.I. ______ Country ___________

2. Street Address ___________________________________________________ Apartment/ Unit # ______________

City ________________ State/ Province ________________ ZIP Code ____________ Alt. Phone ______________

3. Primary Phone ________________ E-mail Address ____________________________________________________

A. APPLICANT’S INFORMATION (REQUIRED FOR ALL SUBMISSIONS)
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1. Are you, or were you at the time you acquired the original information you submitted to us, a member, officer or

employee of the Department of Justice, the Securities and Exchange Commission (“SEC” or “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?

F. ELIGIBILITY REQUIREMENTS AND OTHER INFORMATION

YES NO

2. Are you, or were you at the time you acquired the original information you submitted 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 obtain the information you are providing to us through the performance of an engagement required

under the federal securities laws by an independent public accountant?

4. Did you provide the information identified in Section C above pursuant to a cooperation agreement with the SEC

or another agency or organization?

5. Are you a spouse, parent, child, or sibling of a member or employee of the Commission, or do you reside in the

same household as a member or employee of the Commission?

YES NO

YES NO

YES NO

1. Date of Notice of Covered Action to which claim relates _____________ 2. Notice Number __________________

3a. Case Name __________________________________ 3b. Case Number___________________________________

D. NOTICE OF COVERED ACTION (https://www.sec.gov/whistleblower/claim-award)

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

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

3a. Date you provided your information ___________ 3b. Date action filed by agency/organization _____________

4a. Case Name _________________________________ 4b. Case number ____________________________________

E. CLAIMS PERTAINING TO RELATED ACTIONS

A "Related Action" may include certain judicial or administrative actions brought by an authority other than the SEC. 
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Explain the basis for your belief that you are entitled to an award in connection with your submission of

information to us, or to another agency in a related action. Provide any additional information you think may be 

relevant in light of the criteria for determining the amount of an award set forth in Rule 21F-6 under the Securities 

Exchange Act of 1934. Include any supporting documents in your possession or control, and attach additional 

sheets, if necessary.

G. ENTITLEMENT TO AWARD

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.

H. DECLARATION

Signature __________________________________________________ Date _________________________________ 

 

6. Did you acquire the information you are providing to us from any person described in questions F1 through F5?

7. Did you provide the information identified in Section C above after 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?

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 upon which your application for an award is based?

9. If you answered “Yes” in response to any of the above eight questions, please provide a detailed response 

explaining your answer. Use additional sheets if necessary.

YES NO

YES NO

YES NO
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Privacy Act Statement

This notice is given under the Privacy Act of 1974. We are authorized to request information from you by 

Section 21F of the Securities Exchange Act of 1934. Our principal purpose in requesting this information is 

to assist in our evaluation of your eligibility and other factors relevant to our determination of whether to pay 

a whistleblower award to you under Section 21F of the Exchange Act.

However, 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 this information is voluntary, but a decision not do so, or failure to provide complete information, 

may result in our denying a whistleblower award to you, or may affect our evaluation of the appropriate 

amount of an award. Further, if you are submitting this information for the SEC whistleblower program and 

you do not execute the Declaration, you may not be considered for an award.

Questions concerning this form may be directed to the SEC Office of the Whistleblower, 100 F Street, NE, 

Washington, DC 20549-5631, Tel. (202) 551-4790, Fax (703) 813-9322.

General

• This form should be used by persons making a claim for a whistleblower award in connection with 

information provided to the SEC or to another agency in a related action. In order to be deemed eligible 

for an award, you must meet all the requirements set forth in Section 21F of the Securities Exchange Act 

of 1934 and the rules thereunder.

• You must sign the Form WB-APP as the claimant. If you provided your information to the SEC 

anonymously, you must now disclose your identity on this form and your identity must be verified in a 

form and manner that is acceptable to the Office of the Whistleblower prior to the payment of any award.

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

your Form WB-APP, and any attachments thereto, must be received by the SEC Office of 

the Whistleblower within ninety (90) days of the date of the Notice of Covered Action to 

which the claim relates.

° If you are filing your claim in connection with information you provided to another agency in a 

related action, then your Form WB-APP, and any attachments thereto, must be received by the 

SEC Office of the Whistleblower as follows:
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• If a final order imposing monetary sanctions has been entered in a related action at 

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

you must submit your claim for an award in that related action on the same 

Form WB-APP that you use for the Commission action.

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

at the time you submit your claim for an award in connection with a Commission 

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.

• You must submit your Form WB-APP to us in one of the following three ways:

° By EMAIL sent to: FormWB-APPSubmission@SEC.GOV

° By mailing or delivering the signed form to the SEC Office of the Whistleblower, 100 F Street 

NE, Washington, DC 20549-5631; or

° By faxing the signed form to (703) 813-9322.

Instructions for Completing Form WB-APP

Section A: Applicant’s Information

Questions 1-3: Provide the following information about yourself:

• First and last 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

• E-mail address

Section B: Attorney’s Information. If you are represented by an attorney in this matter, provide the 

information requested. If you are not represented by an attorney in this matter, leave this Section 

blank.

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

• Attorney’s name

• Firm name

• Complete address, including city, state and zip code

• Telephone number and fax number, and

• E-mail address
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Section C: Tip/Complaint Details

Question 1: Indicate the manner in which your original information was submitted to the SEC. 

Question 2a: Include the TCR (Tip, Complaint or Referral) number to which this claim relates. 

Question 2b: Provide the date on which you submitted your information to the SEC.

Question 2c: Provide the name of the individual(s) or entity(s) to which your complaint related.

Section D: Notice of Covered Action

The process for making a claim for a whistleblower award begins with the publication of a “Notice of 

Covered Action” on the Commission’s website at: https://www.sec.gov/whistleblower/claim-award. This 

Notice is published whenever a judicial or administrative action brought by the Commission results in the 

imposition of monetary sanctions exceeding $1,000,000. The Notice is published on the Commission’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.

Question 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. 

A "Related Action" may include certain judicial or administrative actions brought by an 

 authority other than the SEC. See Exchange Act Rule 21F-3(b)(1).

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 E1.

Question 3b: Provide the date on which the agency or organization referenced in question E1 filed the 

 related action that was based upon the information you provided.

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

Question 4b: Provide the case number of the related action.
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Section F: Eligibility Requirements

Question 1: State whether you are currently, or were at the time you acquired the original information 

that you submitted 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, or the Municipal 

Securities Rulemaking Board.

Question 2: State whether you are, or were you at the time you acquired the original information you 

submitted 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.

• 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: Indicate whether you acquired the information you provided to the SEC through the 

 performance of an engagement required under the Federal securities laws by an independent 

 public accountant.

Question 4: State whether you provided the information submitted to the SEC 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

 Commission, or whether you reside in the same household as a member or employee of the 

 Commission.

Question 6: State whether you acquired the information you are providing to the SEC from any individual 

 described in Question 1 through 5 of this Section.
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Question 7: State whether you provided the information identified to the SEC after you (or anyone 

 representing you) received any request, inquiry or demand from the SEC, Congress, or any 

 other federal, state or local authority, or any self-regulatory organization, or the Public 

 Company Accounting Oversight Board about a matter to which the information in your 

 submission was relevant.

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 upon which your application for 

 award is based.

Question 9: If you answered “yes” to ANY of the above eight questions, please provide a detailed response 

 explaining your answer. Please provide details, including the name of any agency or 

 organization that conducted an investigation or initiated any action against you, the name and 

 telephone number of your point of contact at the agency or organization, if available and 

the investigation/case name and number, if applicable. Use additional typewritten sheets, 

 if necessary.

Section G: Entitlement to Award

This section is optional. 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 us or to another agency in connection with a 

Related Action. Specifically address how you believe you voluntarily provided the Commission with original 

information that led to the successful enforcement of a judicial or administrative action filed by the 

Commission, or a related action. Refer to Rules 21F-3 and 21F-4 under the Exchange Act for further 

information concerning the relevant award criteria. You may attach additional sheets, if necessary.

Rule 21F-6 under the Exchange Act provides that in determining the amount of the award, the 

Commission will consider certain factors in determining the amount of an award based on the unique 

facts and circumstances of each case. The Commission considers the following positive factors: (i) the 

significance of the information you provided to the success of the proceeding brought against wrongdoers; 

(ii) the extent of the assistance you provide in our investigation and any successful proceeding; (iii) the law 

enforcement interest in deterring violations of the securities laws by making awards to whistleblowers who 

provide information that leads to the successful enforcement of these laws; and (iv) whether, and the extent 

to which, you participated in your company’s internal compliance systems, such as, for example, reporting 

the possible securities violations through internal whistleblower, legal or compliance procedures.
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The Commission also considers the following negative factors: (i) if you were a participant in, or culpable 

for the securities law violation(s) you reported; (ii) if you unreasonably delayed reporting the violation(s) to 

us; and (iii) if you interfered with your company’s internal compliance and reporting systems, such as, for 

example, making false statements to your compliance department that hindered its efforts to investigate 

possible wrongdoing. Additional information about the criteria the Commission may consider in determining 

the amount of an award is available on the Commission’s website at www.sec.gov/whistleblower.

Section H: Declaration

This section must be signed and dated by the claimant.