DODD-FRANK ACT WHISTLEBLOWER TIP SUBMISSION

SEC Whistleblower Program - Form TCR (Tip, Complaint, or Referral)

IMPORTANT NOTICE

AWARD ELIGIBILITY: To be eligible for a whistleblower award of 10-30% of sanctions collected:
- You must provide ORIGINAL information
- The information must be submitted VOLUNTARILY (before any request from the SEC)
- The information must lead to a successful enforcement action
- Monetary sanctions must exceed $1,000,000

ANTI-RETALIATION PROTECTION: You must report in WRITING to the SEC BEFORE experiencing retaliation to qualify for Dodd-Frank anti-retaliation protections.

CONFIDENTIALITY: You may submit anonymously if represented by an attorney.

I. WHISTLEBLOWER INFORMATION

A. Identity Disclosure

Choose One:

☐ Identified Submission - I am providing my identity to the SEC

☐ Anonymous Submission - I am submitting anonymously through an attorney
- Attorney Name: _________________________________
- Attorney Firm: _________________________________
- Attorney Address: _________________________________
- Attorney Phone: _________________________________
- Attorney Email: _________________________________

B. Personal Information (For Identified Submissions)

Full Legal Name: _________________________________

Also Known As: _________________________________

Date of Birth: _________________________________

Social Security Number or Tax ID: _________________________________
(Required if seeking award)

Current Address:

Street: _________________________________

City: _________________________ State: _______ ZIP: ___________

Country (if not U.S.): _________________________________

Contact Information:

Primary Phone: _________________________________

Alternate Phone: _________________________________

Personal Email: _________________________________

Preferred Contact Method: ☐ Phone ☐ Email ☐ Mail

Best Times to Reach You: _________________________________

C. Citizenship/Residency Status

Are you a U.S. citizen or resident?
☐ Yes
☐ No - Country of Citizenship: _________________________________

Are you currently residing outside the United States?
☐ No
☐ Yes - Country of Residence: _________________________________

(Note: Non-U.S. persons may be eligible for SEC whistleblower awards)

II. RELATIONSHIP TO SUBJECT OF TIP

A. Employment Relationship

Current or Former Employee of Subject:
☐ No
☐ Yes

If yes:
Company Name: _________________________________
Position/Title: _________________________________
Dates of Employment: __________ to __________
Department: _________________________________
Current Status: ☐ Current Employee ☐ Former Employee

Other Relationship to Subject:
☐ Contractor/Consultant
☐ Vendor/Supplier
☐ Customer/Client
☐ Investor/Shareholder
☐ Competitor
☐ Industry Participant
☐ No Relationship
☐ Other: _________________________________

B. How You Obtained the Information

Check all that apply:

☐ Through employment duties
☐ Independent investigation or analysis
☐ From public sources (describe below)
☐ From confidential sources
☐ From legal representation of subject
☐ Through government employment (describe below)
☐ Other: _________________________________

Describe how you obtained the information:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

III. SUBJECT OF THE TIP

A. Entity Information

Entity Name: _________________________________

Type of Entity:
☐ Publicly traded company
☐ Private company
☐ Investment adviser
☐ Broker-dealer
☐ Hedge fund
☐ Mutual fund
☐ Municipal securities entity
☐ Individual
☐ Other: _________________________________

Address:

Street: _________________________________

City: _________________________ State: _______ ZIP: ___________

Stock Exchange (if applicable): _________________________________

Ticker Symbol (if applicable): _________________________________

Website: _________________________________

SEC CIK Number (if known): _________________________________

B. Individual(s) Involved

IV. DESCRIPTION OF VIOLATION

A. Type of Securities Violation

Check all that apply:

☐ Offering Fraud
☐ Unregistered securities offering
☐ Fraudulent offering documents
☐ Ponzi scheme
☐ Pyramid scheme

☐ Market Manipulation
☐ Pump and dump scheme
☐ Spoofing
☐ Layering
☐ Wash trading
☐ Marking the close
☐ Other manipulation: _________________________________

☐ Insider Trading
☐ Trading on material non-public information
☐ Tipping material non-public information
☐ Front-running

☐ Financial Fraud/Disclosure Violations
☐ Accounting fraud
☐ Falsified financial statements
☐ Failure to disclose material information
☐ Earnings manipulation
☐ Improper revenue recognition
☐ Off-balance sheet liabilities

☐ Foreign Corrupt Practices Act (FCPA)
☐ Foreign bribery
☐ Books and records violations
☐ Internal controls failures

☐ Investment Adviser/Fund Violations
☐ Breach of fiduciary duty
☐ Improper allocation of trades
☐ Cherry-picking
☐ Improper fee arrangements
☐ Failure to disclose conflicts of interest
☐ Valuation fraud

☐ Broker-Dealer Violations
☐ Unauthorized trading
☐ Churning
☐ Excessive commissions
☐ Unsuitable recommendations
☐ Best execution failures

☐ Municipal Securities Violations
☐ Pay-to-play violations
☐ Offering document fraud

☐ Other Violations:
_________________________________

B. Detailed Description of Violation

Provide a comprehensive description of the potential securities law violation:

Include: Who did what? When did it happen? How was it done? What laws/rules were violated?

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

C. How the Violation Was Concealed (if applicable)

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

D. Harm to Investors/Market

Describe the harm or potential harm to investors or the securities markets:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Estimated Investor Losses: $__________________

Number of Affected Investors (if known): __________________

V. TIMELINE OF EVENTS

Is the violation ongoing?
☐ Yes - Still occurring as of: _________________________________
☐ No - Ended approximately: _________________________________
☐ Unknown

VI. SUPPORTING EVIDENCE

A. Documentary Evidence

B. Documents Known to Exist

C. Witnesses

D. Electronic Evidence

Describe any electronic evidence (emails, databases, trading records, etc.):

_____________________________________________________________________________

_____________________________________________________________________________

VII. PRIOR REPORTING

A. Reports to Company/Entity

Have you reported this matter internally to the company?
☐ No
☐ Yes

If yes:
To Whom: _________________________________
Date(s): _________________________________
Method: ☐ Written ☐ Verbal ☐ Hotline ☐ Other: _____________
Response Received: _________________________________

B. Reports to Other Authorities

Have you reported this matter to any other government agency?
☐ No
☐ Yes

If yes:
Agency: _________________________________
Date: _________________________________
Reference Number: _________________________________
Status: _________________________________

Other agencies contacted:

C. Other Whistleblowers

Are you aware of others who may have reported this violation?
☐ No
☐ Yes - Describe: _________________________________

VIII. ORIGINALITY OF INFORMATION

A. Public Disclosure

Has this information been publicly disclosed?
☐ No
☐ Partially - Describe what has been disclosed:
_________________________________
☐ Yes - Describe:
_________________________________

B. Source of Information

Is your information derived solely from any of the following?

☐ No - My information is NOT derived from any of the following sources

☐ A judicial or administrative hearing
☐ A government audit or investigation
☐ A government report, hearing, or investigation
☐ News media

If yes to any above, explain how your information provides additional, original information:

_____________________________________________________________________________

_____________________________________________________________________________

C. Independent Analysis

Does your submission include independent analysis?
☐ No
☐ Yes - Describe your analysis:

_____________________________________________________________________________

_____________________________________________________________________________

IX. ELIGIBILITY CONSIDERATIONS

A. Employment Background

Are you, or were you at the time you acquired the information:

☐ An officer, director, trustee, or partner of the entity
☐ An employee whose principal duties involve compliance or internal audit
☐ An employee of a registered public accounting firm
☐ A person who obtained the information through an attorney-client communication
☐ An employee or contractor of a government agency
☐ None of the above

If you checked any of the above, you may still be eligible under certain exceptions. Describe your situation:

_____________________________________________________________________________

_____________________________________________________________________________

B. Exclusions from Award

Check if any apply:

☐ I am/was a member, officer, or employee of the SEC, DOJ, or certain other agencies
☐ I obtained information through an attorney-client privileged communication
☐ I obtained information in connection with legal representation
☐ I am a foreign government official
☐ I am convicted of a criminal violation related to this matter

X. AWARD ELECTION

If eligible, do you wish to be considered for an award?

☐ Yes - I wish to be considered for a whistleblower award if the SEC brings a successful enforcement action based on my information

☐ No - I do not wish to be considered for an award

(Note: Even if you elect "No," you may still qualify for anti-retaliation protections)

XI. ANTI-RETALIATION

A. Current Status

Have you experienced any retaliation for reporting this matter?
☐ No
☐ Yes

If yes:
Nature of Retaliation:
☐ Termination
☐ Demotion
☐ Suspension
☐ Threats
☐ Harassment
☐ Reduction in pay/benefits
☐ Other: _________________________________

Date(s) of Retaliation: _________________________________

By Whom: _________________________________

Have you filed a retaliation complaint?
☐ No
☐ Yes - Where: _________________________________
Case/Charge Number: _________________________________

B. Fear of Retaliation

Do you fear potential retaliation?
☐ No
☐ Yes - Describe concerns:

_____________________________________________________________________________

XII. DECLARATIONS AND CERTIFICATIONS

Declaration Under Penalty of Perjury

I declare under penalty of perjury under the laws of the United States that the information contained in this submission is true and correct to the best of my knowledge, information, and belief.

I understand that I may be subject to liability for any false statements or omissions.

Signature: _________________________________

Printed Name: _________________________________

Date: _________________________________

Certification Regarding Award Eligibility

If seeking an award, I certify that:

1. I am submitting this information voluntarily.

2. I am submitting original information to the SEC based on my independent knowledge or independent analysis.

3. I have not obtained my information from any source that would make me ineligible for an award.

4. I am not an officer, director, or employee of a U.S. government agency or entity, or a member of a foreign government.

5. I have not been convicted of a criminal violation related to the securities violation being reported.

Signature: _________________________________

Date: _________________________________

STATE-SPECIFIC NOTES

California

California has additional whistleblower protections under Labor Code § 1102.5 and the California False Claims Act. California employees may have parallel claims for retaliation under state law with potentially broader protections and a 3-year statute of limitations.

New York

New York Labor Law § 740 provides additional whistleblower protections. The Martin Act provides the NY Attorney General with broad authority over securities matters. Consider whether state-level reporting is also appropriate.

Texas

The Texas Securities Act (Tex. Rev. Civ. Stat. Art. 581-1 et seq.) is enforced by the Texas State Securities Board. Texas has limited whistleblower protections for private sector employees, so federal Dodd-Frank protections are particularly important.

Florida

Florida Securities and Investor Protection Act (Fla. Stat. Ch. 517) is enforced by the Florida Office of Financial Regulation. Florida Whistleblower Act (Fla. Stat. § 448.102) provides additional protections for private sector employees (10+ employees) effective July 1, 2025.

SUBMISSION INSTRUCTIONS

Online Submission (Preferred)

SEC Tips, Complaints, and Referrals Portal:
https://www.sec.gov/tcr

Mail Submission

Address:
Securities and Exchange Commission
Office of the Whistleblower
100 F Street, NE
Mail Stop 5631
Washington, DC 20549

Fax Submission

Fax: (703) 813-9322

WHAT HAPPENS AFTER SUBMISSION

1. Acknowledgment: The SEC will acknowledge receipt of your submission

2. Assignment: Your tip will be assigned to appropriate SEC staff for review

3. Evaluation: Staff will evaluate whether to open an investigation

4. Investigation: If warranted, the SEC will conduct an investigation

5. Enforcement Action: If violations are found, the SEC may bring an enforcement action

6. Award Determination: If an enforcement action results in sanctions over $1 million, you may apply for an award

7. Award Payment: Awards of 10-30% are paid from the SEC's Investor Protection Fund

Note: The SEC does not routinely provide updates on the status of tips. You may check the SEC's enforcement actions for cases related to your tip.

CONTACT INFORMATION

SEC Office of the Whistleblower
Phone: (202) 551-4790
Email: [email protected]
Website: www.sec.gov/whistleblower

ATTACHMENTS CHECKLIST

☐ Supporting documents (financial records, communications, etc.)
☐ Timeline of events
☐ List of witnesses
☐ If anonymous: Attorney authorization letter
☐ If claiming award: Form WB-DEC (Declaration)

This template is provided for educational purposes only and does not constitute legal advice. SEC whistleblower submissions are complex and the rules regarding eligibility for awards are intricate. Consult with an attorney experienced in SEC whistleblower matters before submitting your tip.