SEC WHISTLEBLOWER SUBMISSION AND AWARD APPLICATION

Securities Exchange Act Section 21F Program

PROGRAM OVERVIEW

The SEC Whistleblower Program, established by the Dodd-Frank Act, provides monetary awards to eligible individuals who provide original information that leads to successful SEC enforcement actions with monetary sanctions exceeding $1 million.

Award Range: 10% to 30% of collected monetary sanctions

Since Program Inception (2011): Over $2 billion awarded to whistleblowers

PART I: TIP, COMPLAINT, OR REFERRAL (TCR)

Section A: Whistleblower Information

1. Submission Type

☐ Identified Submission - Providing full identity to SEC
☐ Anonymous Submission - Submitting through legal counsel

Note: Anonymous submissions REQUIRE attorney representation. You must provide your identity before award payment.

2. Whistleblower Identity

If Identified Submission:

Full Legal Name: _________________________________

Other Names Used: _________________________________

Date of Birth: _________________________________

Social Security Number: _________________________________
(Required for award eligibility)

Current Address:

Street: _________________________________

City: _________________ State: _______ ZIP: _________

Country: _________________________________

Contact Information:

Primary Phone: _________________________________

Secondary Phone: _________________________________

Personal Email: _________________________________

Best Time to Contact: _________________________________

If Anonymous Submission:

Attorney Name: _________________________________

Firm Name: _________________________________

Firm Address: _________________________________

Attorney Phone: _________________________________

Attorney Email: _________________________________

Attorney Bar Number: _________________________________

Section B: Subject of Tip

1. Primary Subject

Company/Entity Name: _________________________________

Ticker Symbol: _________________ Exchange: _________________

Company Address:

_____________________________________________________________________________

Company Website: _________________________________

SEC CIK Number (if known): _________________________________

Entity Type:
☐ Public Company
☐ Investment Adviser
☐ Broker-Dealer
☐ Hedge Fund/Private Fund
☐ Mutual Fund
☐ Municipal Entity
☐ Private Company
☐ Individual(s)
☐ Other: _________________________________

2. Individuals Involved

Individual 1:
Name: _________________________________
Title/Position: _________________________________
Role in Violation: _________________________________
Contact Information: _________________________________

Individual 2:
Name: _________________________________
Title/Position: _________________________________
Role in Violation: _________________________________
Contact Information: _________________________________

Individual 3:
Name: _________________________________
Title/Position: _________________________________
Role in Violation: _________________________________
Contact Information: _________________________________

(Attach additional pages if necessary)

Section C: Violation Information

1. Category of Violation

Check all applicable categories:

Offering Fraud:
☐ Securities offering fraud
☐ Unregistered securities offerings
☐ Ponzi/Pyramid schemes
☐ Affinity fraud

Corporate Disclosure and Financial Statement Fraud:
☐ Materially false/misleading statements in SEC filings
☐ Accounting fraud
☐ Revenue recognition fraud
☐ Expense manipulation
☐ Asset/liability misstatement
☐ Failure to disclose material information
☐ MD&A disclosure failures

Market Manipulation:
☐ Pump and dump schemes
☐ Spoofing/Layering
☐ Wash trading
☐ Marking the close
☐ Naked short selling
☐ Other manipulation: _________________________________

Insider Trading:
☐ Trading on MNPI
☐ Tipping MNPI
☐ Front-running
☐ Rule 10b5-1 plan violations

Investment Adviser/Fund Violations:
☐ Breach of fiduciary duty
☐ Conflicts of interest failures
☐ Best execution violations
☐ Cherry-picking/Trade allocation fraud
☐ Fee/expense fraud
☐ Performance reporting fraud
☐ Custody rule violations

Broker-Dealer Violations:
☐ Churning
☐ Unauthorized trading
☐ Unsuitable recommendations
☐ Excessive markups/markdowns
☐ Failure to supervise

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

Other Violations:
☐ Regulation S-P (privacy) violations
☐ Regulation SHO violations
☐ Municipal securities violations
☐ Credit rating agency violations
☐ Crowdfunding violations
☐ Regulation A violations
☐ Other: _________________________________

2. Detailed Description of Violation

Provide a comprehensive narrative of the violation(s):

Include: What happened? Who was involved? When did it occur? How was it accomplished? What securities laws were violated?

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

3. Timeline

Is the violation ongoing?
☐ Yes - Continuing as of: _________________________________
☐ No - Ended approximately: _________________________________

4. Harm Assessment

Estimated investor losses: $__________________

Estimated ill-gotten gains by violator: $__________________

Number of affected investors: __________________

Other harm to investors/markets:

_____________________________________________________________________________

Section D: Your Relationship to Information

1. Employment/Relationship with Subject

Current or former employee?
☐ No
☐ Yes

If yes:
Employer Name: _________________________________
Position: _________________________________
Dates: __________ to __________
Department: _________________________________

Other relationship:
☐ Contractor/Consultant
☐ Customer/Client
☐ Investor/Shareholder
☐ Business Partner
☐ Competitor
☐ No relationship
☐ Other: _________________________________

2. How You Obtained Information

☐ Through job duties
☐ Independent research/analysis
☐ Observation/personal knowledge
☐ Communications with others
☐ Public sources plus analysis
☐ Other: _________________________________

Detailed explanation:

_____________________________________________________________________________

_____________________________________________________________________________

Section E: Supporting Evidence

1. Documents You Are Providing

2. Documents Known to Exist

3. Witnesses

Section F: Prior Reporting

1. Internal Reporting

Did you report internally?
☐ No
☐ Yes

If yes:
To whom: _________________________________
Date(s): _________________________________
Method: _________________________________
Response: _________________________________

2. Other Government Agencies

Reported to other agencies?
☐ No
☐ Yes

If yes, list agencies:

3. Media Contact

Have you contacted media about this matter?
☐ No
☐ Yes - Describe: _________________________________

PART II: AWARD ELIGIBILITY

Section A: Voluntary Submission

☐ I am providing this information VOLUNTARILY

☐ I am providing this information BEFORE any request, inquiry, or demand from the SEC related to this subject matter

☐ I am NOT providing this information in response to any government request

Section B: Original Information

Check all that apply:

☐ My information is derived from my independent knowledge
☐ My information is derived from my independent analysis
☐ My information is NOT derived from:
☐ Judicial or administrative hearings
☐ Government reports, hearings, audits, or investigations (unless I am original source)
☐ News media (unless I am original source)

Section C: Potential Exclusions

Are you or were you:

☐ A member, officer, or employee of the SEC, DOJ, PCAOB, CFTC, or self-regulatory organization?
☐ A foreign government official?
☐ Convicted of a criminal violation related to this matter?
☐ Did you obtain information through attorney-client privileged communication?

Are you:

☐ An officer, director, trustee, or partner of the entity (within 120 days)?
☐ An employee whose principal duties involve compliance or internal audit?
☐ An employee of a public accounting firm (for audit client information)?
☐ A person who learned of the violations from a person described above?

If you checked any above, you may still qualify under certain exceptions. Consult legal counsel.

Section D: Culpability Disclosure

Were you involved in the conduct you are reporting?
☐ No
☐ Yes - Describe your involvement:

_____________________________________________________________________________

_____________________________________________________________________________

Note: Participation in wrongdoing may affect your award but does not necessarily disqualify you.

PART III: DECLARATIONS

Declaration 1: Truthfulness

I declare under penalty of perjury under the laws of the United States that the information I have provided is true and correct to the best of my knowledge, information, and belief.

I understand that I am subject to 18 U.S.C. § 1001 for any false statements.

Signature: _________________________________

Printed Name: _________________________________

Date: _________________________________

Declaration 2: Original Information

I declare that:

1. I am providing information to the SEC voluntarily.

2. I am providing original information that is based on my independent knowledge or independent analysis.

3. I have not obtained my information through any of the channels that would make me ineligible for an award.

4. My submission was not made to the SEC in response to any request, inquiry, or demand from the SEC.

Signature: _________________________________

Date: _________________________________

Declaration 3: Non-Interference

I declare that I have not and will not:

1. Knowingly or recklessly interfere with the SEC's investigation

2. Make any false statements to the SEC

3. Destroy or conceal evidence relevant to the SEC's investigation

Signature: _________________________________

Date: _________________________________

PART IV: ANTI-RETALIATION PROTECTION

Current Retaliation Status

Have you experienced retaliation?
☐ No
☐ Yes

If yes:
Type of retaliation: _________________________________
Date(s): _________________________________
By whom: _________________________________

Have you filed a retaliation claim?
☐ No
☐ Yes - Where: _________________________________

Dodd-Frank Anti-Retaliation Rights

Under Section 21F(h)(1), employers may not retaliate against employees who:
- Provide information to the SEC
- Initiate, testify in, or assist in SEC investigations
- Make disclosures required or protected under SOX, the Exchange Act, or other laws

Available Remedies for Retaliation:
- Reinstatement with same seniority
- 2x back pay plus interest
- Litigation costs, expert fees, and attorneys' fees

Statute of Limitations: 6 years from date of retaliation (or 3 years from when facts were known or reasonably should have been known, but not more than 10 years)

STATE-SPECIFIC NOTES

California

California Labor Code § 1102.5 provides parallel whistleblower protections. California employees may pursue both federal Dodd-Frank claims and state law claims. California allows for attorney's fees and has a 3-year statute of limitations for retaliation claims.

New York

New York Labor Law § 740 (as amended 2022) provides broad whistleblower protections covering violations of any law, rule, or regulation. The Martin Act grants the NY Attorney General broad securities enforcement authority. Parallel state claims may be appropriate.

Texas

Texas has limited state-level whistleblower protections for private sector employees. The Texas State Securities Board enforces state securities laws. Federal Dodd-Frank protections are particularly important for Texas private sector employees.

Florida

Florida Office of Financial Regulation enforces state securities laws. Florida Whistleblower Act (Fla. Stat. § 448.102) provides protections for private sector employees at companies with 10+ employees (expanded effective July 1, 2025). Consider parallel state claims.

SUBMISSION INSTRUCTIONS

Online Submission (Preferred)

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

Create an account and submit electronically for fastest processing.

Mail Submission

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

Fax Submission

(703) 813-9322

AFTER SUBMISSION

TCR Number

Upon submission, you will receive a TCR (Tip, Complaint, or Referral) number. SAVE THIS NUMBER - you will need it for:
- Checking status
- Submitting additional information
- Filing an award application

Your TCR Number: _________________________________

Investigation Timeline

1. Initial Review: SEC staff reviews the submission
2. Assignment: If actionable, assigned to enforcement staff
3. Investigation: SEC investigates (may take months to years)
4. Enforcement Action: If violations confirmed, SEC may bring action
5. Award Application: After successful action, you may apply for award

Award Application Process

After a successful enforcement action:
1. SEC posts Notice of Covered Action
2. You have 90 days to submit Form WB-APP (Award Application)
3. Claims Review Staff evaluates application
4. Preliminary determination issued
5. Opportunity to contest if determination is adverse
6. Final Order by SEC

FORM WB-APP PREVIEW

(To be filed after successful enforcement action)

Case Information:
SEC Action Name: _________________________________
SEC Case Number: _________________________________
Notice of Covered Action Number: _________________________________
TCR Number(s): _________________________________

Claimant Information:
(Same as TCR submission)

Contribution Statement:
Describe how your information contributed to the success of the enforcement action:

_____________________________________________________________________________

_____________________________________________________________________________

CONTACT INFORMATION

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

Whistleblower Hotline: 1-833-SEC-0808

ATTACHMENTS CHECKLIST

☐ Completed TCR form (all sections)
☐ Declaration of truthfulness (signed)
☐ Declaration of original information (signed)
☐ Supporting documents (organized and labeled)
☐ Witness list
☐ Timeline of events
☐ If anonymous: Attorney authorization letter
☐ If anonymous: Form WB-DEC (separate declaration)

This template is provided for educational purposes only and does not constitute legal advice. SEC whistleblower submissions involve complex eligibility rules and procedural requirements. The SEC whistleblower program has awarded over $2 billion to whistleblowers whose tips led to successful enforcement actions. Consult an attorney experienced in SEC whistleblower matters to maximize your award eligibility.