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Form TCR Tip Complaint Or Referral (SEC2850) TCR - Official Federal Forms
| Form TCR Tip Complaint Or Referral (SEC2850) Form. This is a national form and can be used in Securities And Exchange Commission . |
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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, DC 20549 FORM TCR TIP, COMPLAINT OR REFERRAL A. INFORMATION ABOUT YOU OMB APPROVAL OMB Number: . . . . . 3235-0686 Expires: . . . . . . August 31, 2014 Estimated average burden hours per response. . . . . . . . . 1 COMPLAINANT 1: 1. Last Name 2. Street Address State/ Province ZIP/ Postal Code First M.I. Apartment/ Unit # City 3. Telephone Alt. Phone E-mail Address Country Preferred method of communication 4. Occupation COMPLAINANT 2: 1. Last Name First M.I. Apartment/ Unit # State/ Province ZIP/ Postal Code 2. Street Address City 3. Telephone Alt. Phone E-mail Address Country Preferred method of communication 4. Occupation B. ATTORNEY'S INFORMATION (If Applicable - See Instructions) 1. Attorney's Name 2. Firm Name 3. Street Address State/ Province ZIP/ Postal Code City Country 4. Telephone Fax E-mail Address SEC2850 (08-11) 1 American LegalNet, Inc. www.FormsWorkFlow.com C. TELL US ABOUT THE INDIVIDUAL OR ENTITY YOU HAVE A COMPLAINT AGAINST If an individual, specify profession: Entity If an entity, specify type: INDIVIDUAL/ENTITY 1: 1. Type: Individual 2. Name Apartment/ Unit # State/ Province ZIP/ Postal Code 3. Street Address City Country 4. Phone INDIVIDUAL/ENTITY 2: 1. Type: Individual Entity E-mail Address If an individual, specify profession: If an entity, specify type: Internet address 2. Name Apartment/ Unit # 3. Street Address State/ Province ZIP/ Postal Code City Country 4. Phone E-mail Address Internet Address D. TELL US ABOUT YOUR COMPLAINT / / 2. Nature of complaint: 1. Occurrence Date (mm/dd/yyyy): 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 4b. If the answer to 4a is "Yes," please provide details. Use additional sheets if necessary. NO 4c. Name and contact information for point of contact at agency or organization, if known SEC2850 (08-11) 2 American LegalNet, Inc. www.FormsWorkFlow.com 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? 5c. If the answer to question 5b is "yes," please provide details. Use additional sheets if necessary. YES NO 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? 6b. If the answer to question 6a is "yes," please provide details. Use additional sheets if necessary. YES NO 7a. Type of security or investment, if relevant 7c. Security/ 7b. Name of issuer or security, if relevant 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. SEC2850 (08-11) 3 American LegalNet, Inc. www.FormsWorkFlow.com 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. SEC2850 (08-11) 4 American LegalNet, Inc. www.FormsWorkFlow.com 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. ยง78c(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 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. Are you providing this information before 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 gove
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