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Form WB-APP Application For Award For Original Information (SEC2851) WB-APP - Official Federal Forms
| Form WB-APP Application For Award For Original Information (SEC2851) 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 WB-APP OMB APPROVAL OMB Number: . . . . . 3235-0686 Expires: . . . . . . August 31, 2014 Estimated average burden hours per response. . . . . . . . . 2 APPLICATION FOR AWARD FOR ORIGINAL INFORMATION SUBMITTED PURSUANT TO SECTION 21F OF THE SECURITIES EXCHANGE ACT OF 1934 A. APPLICANT'S INFORMATION (REQUIRED FOR ALL SUBMISSIONS) First M.I. Social Security No. Apartment/ Unit # State/ Province Alt. Phone ZIP Code E-mail Address Country 1. Last Name 2. Street Address City 3. Telephone B. ATTORNEY'S INFORMATION (IF APPLICABLE SEE INSTRUCTIONS) 1. Attorney's name 2. Firm Name 3. Street Address City 4. Telephone State/ Province Fax ZIP Code E-mail Address Country C. TIP/COMPLAINT DETAILS 1. Manner in which original information was submitted to SEC: 2a. Tip, Complaint or Referral number 2c. Subject(s) of the Tip, Complaint or Referral: SEC website Mail Fax Other ______________ / / 2b. Date TCR referred to in 2a submitted to SEC D. NOTICE OF COVERED ACTION 1. Date of Notice of Covered Action to which claim relates: 3a. Case Name / / 2. Notice Number: 3b. Case Number E. CLAIMS PERTAINING TO RELATED ACTIONS 1. Name of agency or organization to which you provided your information 2. Name and contact information for point of contact at agency or organization, if known. 3a. Date you provided your information 4a. Case Name / / 3b. Date action filed by agency/organization 4b. Case number / / F. ELIGIBILITY REQUIREMENTS AND OTHER INFORMATION 1. Are you, or were you at the time you acquired the original information you submitted 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, the Municipal Securities Rulemaking Board? YES NO SEC2851 (08-11) 1 American LegalNet, Inc. www.FormsWorkFlow.com 2. Are you, or were you at the time you acquired the original information you submitted 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 obtain the information you are providing to us through the performance of an engagement required under the federal securities NO laws by an independent public accountant? YES 4. Did you provide the information identified in Section C above pursuant to a cooperation agreement with the SEC or another agency or NO organization? YES 5. Are you a spouse, parent, child, or sibling of a member or employee of the Commission, or do you reside in the same household as a member or employee of the Commission? YES NO 6. Did you acquire the information you are providing to us from any person described in questions F1 through F5? YES NO 7. If you answered "yes" to any of questions 1 through 6 above, please provide details. Use additional sheets if necessary. 8a. Did you provide the information identified in Section C above 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 government, or a state Attorney General or securities regulatory authority? YES NO 8b. If you answered "yes" to question 8a, please provide details. Use additional sheets if necessary. 9a. 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 upon which your application for an award is based? YES NO 9b. If you answered "Yes" to question 9a, please provide details. Use additional sheets if necessary. G. ENTITLEMENT TO AWARD Explain the basis for your belief that you are entitled to an award in connection with your submission of information to us, or to another agency in a related action. Provide any additional information you think may be relevant in light of the criteria for determining the amount of an award set forth in Rule 21F-6 under the Securities Exchange Act of 1934. Include any supporting documents in your possession or control, and attach additional sheets, if necessary. H. 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. Signature Date SEC2851 (08-11) 2 American LegalNet, Inc. www.FormsWorkFlow.com Privacy Act Statement This notice is given under the Privacy Act of 1974. We are authorized to request information from you by Section 21F of the Securities Exchange Act of 1934. Our principal purpose in requesting this information is to assist in our evaluation of your eligibility and other factors relevant to our determination of whether to pay a whistleblower award to you under Section 21F of the Exchange Act. However, 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
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