UNITED STATES 

SECURITIES AND EXCHANGE COMMISSION 

Washington, DC 20549 

FORM TCR 

TIP, COMPLAINT OR REFERRAL 

A. INFORMATION ABOUT YOU 

COMPLAINANT 1: 

1. Last Name First M.I. 

2. Street Address 

Apartment/ 

Unit # 

City 

State/ 

Province 

ZIP/ 

Postal Code Country 

3. Telephone Alt. Phone E-mail Address 

4. Occupation 

Preferred 

method of 

communication 

COMPLAINANT 2: 

1. Last Name First M.I. 

2. Street Address 

Apartment/ 

Unit # 

City 

State/ 

Province 

ZIP/ 

Postal Code Country 

3. Telephone Alt. Phone E-mail Address 

4. Occupation 

Preferred 

method of 

communication 

B. 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 
C. TELL US ABOUT THE INDIVIDUAL OR ENTITY YOU HAVE A COMPLAINT AGAINST 

INDIVIDUAL/ENTITY 1: 

1. Type: Individual Entity 

If an individual, specify profession: 

If an entity, specify type: 

2. Name 

3. Street Address 

Apartment/ 

Unit # 

City 

State/ 

Province 

ZIP/ 

Postal Code Country 

4. Phone E-mail Address Internet Address 

INDIVIDUAL/ENTITY 2: 

1. Type: Individual Entity 

If an individual, specify profession: 

 

If an entity, specify type:

2. Name 

3. Street Address 

Apartment/ 

Unit # 

City 

State/ 

Province 

ZIP/ 

Postal Code Country 

4. Phone E-mail Address Internet Address 

D. 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 

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? YES NO 

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

 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. 

 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. 

 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: 

 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 your 

email address), 

 Your preferred method of communication; and 

 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: 

 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 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: 

 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). 

 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: 

 Full name 

 Complete address, including city, state and zip code 

 Telephone number, 

 E-mail address, and 

 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. 

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

 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) 

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

 Registration violations (unregistered securities offering) 

 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) 

 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) 

 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) 

 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) 

 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. 

 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) 

 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; 

 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: 

 1031 exchanges 

 529 plans 

 American Depositary Receipts 

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

 Asset-backed securities 

 Auction rate securities 

 Banking products (including credit cards) 

 Certificates of deposit (CDs) 

 Closed-end funds 

 Coins and precious metals (gold, silver, etc.) 
 Collateralized mortgage obligations (CMOs) 

 Commercial paper 

 Commodities (currency transactions, futures, stock index options) 

 Convertible securities 

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

 Equities (exchange-traded, foreign, Over-the-Counter, unregistered, linked notes) 

Exchange Traded Funds 

 Franchises or business ventures 

 Hedge funds 

 Insurance contracts (not annuities) 

 Money-market funds 

 Mortgage-backed securities (mortgages, reverse mortgages) 

 Mutual funds 

 Options (commodity options, index options) 

 Partnerships 

 Preferred shares 

 Prime bank securities/high yield programs 

 Promissory notes 

 Real estate (real estate investment trusts (REITs)) 

 Retirement plans ( 401(k), IRAs) 

 Rights and warrants 

 Structured note products 

 Subprime issues 

 Treasury securities 

 U.S. government agency securities 

 Unit investment trusts (UIT) 

 Viaticals and life settlements 

 Wrap accounts 

 Separately Managed Accounts (SMAs) 

 Unknown 

 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. 

 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.