SEC COMPLAINT / TIP / WHISTLEBLOWER SUBMISSION

Form TCR - Tips, Complaints, and Referrals

IMPORTANT INFORMATION

Purpose of This Form

This form is used to submit information to the U.S. Securities and Exchange Commission (SEC) regarding potential violations of federal securities laws.

Types of Submissions

1. General Tip/Complaint: Information about potential securities violations
2. Whistleblower Tip (Form TCR): Information that may qualify for financial awards under the SEC Whistleblower Program

SEC Whistleblower Program

• You may be eligible for a monetary award of 10-30% of sanctions collected if your tip leads to a successful enforcement action resulting in monetary sanctions exceeding $1 million.
• To be eligible for an award, you must submit your information through the SEC's online TCR portal OR complete Form TCR and answer "yes" to participating in the whistleblower program.
• You may submit anonymously, but you must be represented by an attorney to be eligible for an award if submitting anonymously.

SECTION 1: SUBMITTER INFORMATION

A. Are You Participating in the Whistleblower Program?

☐ YES - I am submitting this information under the SEC's whistleblower program and wish to be considered for a potential award.

☐ NO - I am submitting this as a general tip/complaint and am NOT seeking a whistleblower award.

IMPORTANT: If you answer YES, you must complete the Whistleblower Declaration at the end of this form.

B. Identity Information

Are you submitting this tip anonymously?
☐ Yes ☐ No

If submitting anonymously: You must be represented by an attorney to be eligible for a whistleblower award. Your attorney's information will be used for communication.

If NOT Submitting Anonymously:

Full Legal Name: _________________________

Address:
_________________________
_________________________

City: _________________________ State: _______ ZIP: ___________

Country: _________________________

Telephone: _________________________ Email: _________________________

Preferred Contact Method:
☐ Email ☐ Telephone ☐ Mail

If Submitting Anonymously:

Attorney Name: _________________________

Law Firm: _________________________

Attorney Bar Number: _________________________ State: _______

Attorney Address:
_________________________
_________________________

Attorney Telephone: _________________________ Attorney Email: _________________________

C. Your Relationship to the Information

How did you learn about this potential violation?

☐ Current employee of company involved
☐ Former employee of company involved
☐ Current employee of related entity (auditor, law firm, etc.)
☐ Former employee of related entity
☐ Investor in company or securities involved
☐ Industry participant
☐ Government employee
☐ Through news/media reports
☐ Independent research/analysis
☐ Other: _________________________

If current or former employee:
Company: _________________________
Position: _________________________
Dates of Employment: From _____________ To _____________

SECTION 2: SUBJECT OF COMPLAINT

A. Entity/Individual Information

Primary Subject (Company/Individual):

Name: _________________________

Type:
☐ Public Company
☐ Private Company
☐ Investment Adviser
☐ Broker-Dealer
☐ Hedge Fund/Private Fund
☐ Municipal Entity
☐ Individual
☐ Other: _________________________

Ticker Symbol (if public company): _________________________

CIK Number (if known): _________________________

CRD Number (if broker/adviser): _________________________

Address:
_________________________
_________________________

City: _________________________ State: _______ ZIP: ___________

Website: _________________________

B. Additional Subjects (If Applicable)

Subject 2:
Name: _________________________
Role in Violation: _________________________

Subject 3:
Name: _________________________
Role in Violation: _________________________

Subject 4:
Name: _________________________
Role in Violation: _________________________

SECTION 3: TYPE OF VIOLATION

Check all that apply:

A. Corporate Disclosure and Financial Fraud

☐ Fraudulent Financial Statements
False or misleading financial statements in SEC filings

☐ Accounting Fraud
Manipulation of accounting records or improper accounting practices

☐ Failure to Disclose Material Information
Omission of material information from SEC filings or public statements

☐ False or Misleading Press Releases
Materially false statements in company communications

☐ Revenue Recognition Fraud
Improper recognition of revenue

☐ Asset/Liability Manipulation
Improper recording of assets or liabilities

B. Market Manipulation

☐ Market Manipulation
Manipulation of securities prices through deceptive practices

☐ Pump and Dump Schemes
Artificially inflating stock price then selling

☐ Spoofing/Layering
Placing orders with intent to cancel before execution

☐ Wash Trading
Trades where no change in beneficial ownership occurs

☐ Front Running
Trading ahead of customer orders

C. Insider Trading

☐ Insider Trading
Trading on material non-public information

☐ Tipping
Sharing material non-public information with others who trade

☐ Insider Trading by Officers/Directors
Trading by company insiders on non-public information

D. Offering Fraud

☐ Offering Fraud
Fraud in the offer or sale of securities

☐ Unregistered Securities Offering
Offering securities without proper registration

☐ Ponzi Scheme
Investment fraud paying returns from new investor capital

☐ Pyramid Scheme
Scheme requiring recruitment of new participants

☐ Private Placement Fraud
Fraud in private securities offerings

☐ Cryptocurrency/Digital Asset Fraud
Fraud involving digital assets or initial coin offerings

E. Investment Adviser/Broker-Dealer Violations

☐ Investment Adviser Fraud
Fraud by investment advisers

☐ Broker-Dealer Fraud
Fraud by broker-dealers or registered representatives

☐ Churning/Excessive Trading
Excessive trading to generate commissions

☐ Unsuitable Recommendations
Recommending unsuitable investments

☐ Best Execution Violations
Failure to obtain best execution for customer trades

☐ Custody Violations
Improper handling of customer assets

F. Other Violations

☐ Foreign Corrupt Practices Act (FCPA)
Bribery of foreign officials

☐ Municipal Securities Violations
Fraud in municipal securities

☐ Mutual Fund Violations
Violations involving mutual funds

☐ Regulation SHO Violations
Short selling violations

☐ Beneficial Ownership Reporting
Failure to file or false Section 13/16 reports

☐ Other:
_________________________

SECTION 4: DETAILED DESCRIPTION

A. Summary of Violation

[Provide a brief summary of the potential violation in 2-3 sentences]

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

B. Detailed Narrative

[Provide a complete description of the potential violation. Include: WHO is involved, WHAT happened, WHEN it occurred, WHERE it occurred, WHY you believe it is a violation, and HOW the violation was carried out.]

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

C. Timeline of Events

D. Key Individuals Involved

E. Securities Involved

F. Dollar Amounts Involved

Estimated Investor Losses: $______________

Estimated Ill-Gotten Gains: $______________

Estimated Value of Affected Transactions: $______________

G. Ongoing or Completed

Is the violation ongoing?
☐ Yes - Currently ongoing
☐ No - Completed
☐ Unknown

When did the violation begin? _____________

When did it end (if completed)? _____________

SECTION 5: SUPPORTING INFORMATION

A. How You Obtained This Information

[Describe how you learned of this potential violation]

_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

B. Is This Information Public?

Has this information been made public (in news, SEC filings, litigation, etc.)?
☐ No - This is non-public information
☐ Partially - Some information is public
☐ Yes - This information is publicly available

If public, identify sources: _____________________________________________________

C. Evidence and Documentation

Do you have documents or evidence supporting your allegations?
☐ Yes ☐ No

Types of Evidence Available:

☐ Internal company documents
☐ Emails or electronic communications
☐ Financial records/spreadsheets
☐ SEC filings
☐ Trade records
☐ Audio/video recordings
☐ Witness statements
☐ Contracts or agreements
☐ Board minutes/presentations
☐ Other: _________________________

List of Documents (do not attach to initial submission unless requested):

1. _________________________
2. _________________________
3. _________________________
4. _________________________
5. _________________________

D. Witnesses

Are there others who have knowledge of this violation?
☐ Yes ☐ No

SECTION 6: PRIOR SUBMISSIONS

A. Prior Reports of This Violation

Have you reported this violation to any other entity?

☐ Internal Report (to company)
Date: _____________ To Whom: _________________________
Response: _______________________________________________________________________

☐ Company's Audit Committee/Board
Date: _____________ Response: _________________________

☐ External Auditor
Date: _____________ Response: _________________________

☐ FINRA
Date: _____________ Reference Number: _________________________

☐ State Securities Regulator
State: _____________ Date: _____________ Reference Number: _____________

☐ Department of Justice
Date: _____________ Reference Number: _________________________

☐ Other Government Agency
Agency: _____________ Date: _____________ Reference Number: _____________

☐ None - First report

B. Legal Proceedings

Are you aware of any legal proceedings related to this matter?

☐ Private litigation
Case: _________________________ Court: _________________________ Status: _____________

☐ Government enforcement action
Agency: _________________________ Status: _________________________

☐ None that I am aware of

SECTION 7: WHISTLEBLOWER AWARD ELIGIBILITY

Complete this section ONLY if you answered YES to participating in the whistleblower program in Section 1.

A. Eligibility Questions

1. Are you submitting this information within 120 days of reporting internally to your employer's audit committee, chief legal officer, chief compliance officer, or equivalent?
☐ Yes ☐ No ☐ N/A (did not report internally)

2. Are you or have you been a member, officer, or employee of any of the following in connection with this matter?

☐ Department of Justice
☐ Securities and Exchange Commission
☐ FINRA or other self-regulatory organization
☐ Public Company Accounting Oversight Board
☐ State Attorney General or securities regulator
☐ Other law enforcement or regulatory agency

If yes, specify: _________________________

3. Are you or were you an officer, director, trustee, or partner of an entity AND was another person informed you of allegations related to this submission AND did that person report the violations to the entity's audit committee, chief legal officer, chief compliance officer, or equivalent?
☐ Yes ☐ No

4. Are you providing this information pursuant to a cooperation agreement with the SEC, DOJ, or other government agency?
☐ Yes ☐ No

5. Is the information you are providing derived from the following?

☐ Legal representation of a client
☐ Engagement to perform audit services
☐ Engagement to perform compliance or quality assurance review
☐ None of the above

6. Did you obtain the information through a communication subject to attorney-client privilege?
☐ Yes ☐ No

B. Potential Award Amount

If your tip leads to successful enforcement action(s) with monetary sanctions exceeding $1 million, you may receive an award of 10-30% of the sanctions collected.

SECTION 8: DECLARATIONS

A. Standard Declaration (Required for ALL Submissions)

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.

Signature: _________________________ Date: _____________

Print Name: _________________________

B. Whistleblower Declaration (Required ONLY if Seeking Award)

Complete this section if you answered YES to participating in the whistleblower program.

I declare under penalty of perjury under the laws of the United States of America that, to the best of my knowledge and belief:

1. I am voluntarily providing the information in this tip.

2. I have not obtained, and will not obtain, information that I provide to the SEC through means that violate any federal or state criminal law.

3. The information I am providing is true, correct, and complete to the best of my knowledge, information, and belief, and does not contain any known material misrepresentation.

4. I acknowledge that I may be subject to civil penalties if I make a false, fictitious, or fraudulent statement or representation to a government agency, or if I use a false writing or document knowing the same to contain any false, fictitious, or fraudulent statement or entry.

5. I acknowledge that I may be subject to criminal prosecution if I knowingly and willfully make a false, fictitious, or fraudulent statement or representation, or use a false writing or document knowing the same to contain any false, fictitious, or fraudulent statement or entry in connection with this submission.

Signature: _________________________ Date: _____________

Print Name: _________________________

STATE-SPECIFIC CONSIDERATIONS

California

• California Department of Financial Protection and Innovation (DFPI) accepts securities complaints
• California Corporations Code provides state-level protections
• California's whistleblower protections under Labor Code Section 1102.5
• California False Claims Act may provide additional whistleblower remedies

Texas

• Texas State Securities Board accepts complaints and tips
• Texas Securities Act provides state anti-fraud provisions
• Texas whistleblower protections under Government Code Chapter 554
• Texas may coordinate with SEC on enforcement matters

Florida

• Florida Office of Financial Regulation accepts securities complaints
• Florida Securities and Investor Protection Act (Chapter 517)
• Florida whistleblower protections for private sector employees
• Florida False Claims Act may provide additional remedies

New York

• New York Attorney General's Investor Protection Bureau
• Martin Act provides broad state anti-fraud authority
• New York Department of Financial Services
• New York Labor Law Section 740 provides whistleblower protections

HOW TO SUBMIT

Online Submission (Recommended)

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

• Preferred method for all submissions
• Allows you to track submission status
• Required for whistleblower award eligibility (or use Form TCR)

By Mail

U.S. Securities and Exchange Commission
Office of the Whistleblower
100 F Street NE
Mail Stop 5631
Washington, DC 20549

By Fax

(703) 813-9322

AFTER SUBMISSION

What Happens Next

1. Acknowledgment: You will receive a TCR number for tracking purposes.

2. Evaluation: The Office of Market Intelligence evaluates each tip to identify those warranting additional SEC resources.

3. Assignment: If warranted, the tip may be assigned to SEC Enforcement staff for investigation.

4. Confidentiality: The SEC protects the confidentiality of whistleblowers to the fullest extent possible.

5. Investigation: The SEC will not provide updates on the status of any investigation.

Applying for a Whistleblower Award

If a Covered Action results in monetary sanctions exceeding $1 million, a Notice of Covered Action will be posted at:
https://www.sec.gov/whistleblower/nocas

You have 90 calendar days from posting to submit Form WB-APP to apply for an award.

WHISTLEBLOWER PROTECTIONS

Employment Retaliation Protections

Under Section 21F of the Exchange Act:

• Employers may not discharge, demote, suspend, threaten, harass, or discriminate against whistleblowers.
• Whistleblowers may bring an action in federal court for retaliation.
• Remedies include reinstatement, back pay, and attorneys' fees.

Confidentiality Protections

• The SEC will not disclose information that could reasonably be expected to reveal a whistleblower's identity except:
• When required by law
• In connection with a public proceeding (with possible sealing)
• With whistleblower's consent

RESOURCES

• SEC Whistleblower Program: https://www.sec.gov/whistleblower
• SEC Tips, Complaints, Referrals: https://www.sec.gov/tcr
• SEC Whistleblower FAQs: https://www.sec.gov/whistleblower-faq
• Form TCR (PDF): https://www.sec.gov/files/formtcr.pdf
• Form WB-APP (Award Application): https://www.sec.gov/files/formwb-app.pdf

CHECKLIST BEFORE SUBMITTING

☐ Reviewed all information for accuracy and completeness
☐ Determined whether to participate in whistleblower program
☐ If submitting anonymously, have attorney representation
☐ Identified specific securities law violations
☐ Provided detailed factual information
☐ Listed all supporting documents (do not attach unless requested)
☐ Completed required declarations
☐ Kept copy of submission for records

This template is provided for informational purposes only and does not constitute legal advice. SEC whistleblower submissions involve complex legal requirements and potential financial awards. The decision to become a whistleblower may have significant personal and professional implications. Consult a qualified securities attorney before filing any complaint or tip, especially if seeking whistleblower award eligibility.