Form TCR Tip Complaint Or Referral (SEC2850) {TCR} | Pdf Fpdf Docx | Official Federal Forms

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Form TCR Tip Complaint Or Referral (SEC2850) {TCR} | Pdf Fpdf Docx | Official Federal Forms

Form TCR Tip Complaint Or Referral (SEC2850) {TCR}

This is a Official Federal Forms form that can be used for Securities And Exchange Commission.

Alternate TextLast updated: 1/7/2019

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UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, DC 20549 FORM TCR TIP, COMPLAINT OR REFERRAL A. INFORMATION ABOUT YOU COMPLAINANT 1: 1. Last Name First 2. Street Address Apartment/ Unit # City State/ Province ZIP/ Postal Code Country 3. Telephone Alt. Phone E-mail Address 4. Occupation Preferred method of communication COMPLAINANT 2: 2. Street Address Apartment/ Unit # City State/ Province 3. Telephone Alt. Phone E-mail Address 4. Occupation Preferred method of communication B. ATTORNEY222S INFORMATION (If Applicable - See Instructions) 1. Attorney222s Name 2. Firm Name 3. Street Address City 4. Telephone Fax E-mail Address American LegalNet, Inc. www.FormsWorkFlow.com C. TELL US ABOUT THE INDIVIDUAL OR ENTITY YOU HAVE A COMPLAINT AGAINST INDIVIDUAL/ENTITY 1: 1. Type: Individual Entity If an individual, specify profession: If an entity, specify type: 2. Name 3. Street Address Apartment/ Unit # City State/ Province ZIP/ Postal Code Country 4. Phone E-mail Address Internet Address INDIVIDUAL/ENTITY 2: 1. Type: Individual Entity If an individual, specify profession: If an entity, specify type: 2. Name 3. Street Address Apartment/ Unit # City State/ Province ZIP/ Postal Code Country 4. Phone E-mail Address Internet Address D. TELL US ABOUT YOUR COMPLAINT 1. Occurrence Date (mm/dd/yyyy): / / 2. Nature of complaint: 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 223Yes,224 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 NO 4b. If the answer to 4a is 223Yes,224 please provide details. Use additional sheets if necessary. 4c. Name and contact information for point of contact at agency or organization, if known 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 223Yes,224 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? YES NO 5c. If the answer to question 5b is 223Yes,224 please provide details. Use additional sheets if necessary. 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? YES NO 6b. If the answer to question 6a is 223Yes,224 please provide details. Use additional sheets if necessary. 7a. Does your complaint relate to a residential mortgage-backed security? YES NO 7b. Type of security or investment, if relevant 7c. Name of issuer or security, if relevant 7d. Security/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 complainant222s possession and the availability and location of any additional supporting materials not in complainant222s possession. Use additional sheets, if necessary. 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. 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. 24778c(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 NO 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. Did you acquire the information being provided to us from any person described in questions 1 through 5? YES NO 7. Have 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 8. 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 you are submitting to the SEC? YES NO 9. If you answered 223yes224 to any of the questions 1 through 8, use this space to provide additional details relating to your responses. Use additional sheets if necessary. American LegalNet, Inc. www.FormsWorkFlow.com F. WHISTLEBLOWER222S 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. Print name Signature Date G. COUNSEL CERTIFICATION (If Applicable227See Instructions) I certify that I have reviewed this form for completeness and accuracy and that the information contained herein is true, correct and complete to the best of my knowledge, information and belief. I further certify that I have verified the identity of the whistleblower on whose behalf this form is being submitted by viewing the whistleblower222s valid, unexpired government issued identification (e.g., driver222s license, passport) and will retain an original, signed copy of this form, with Section F signed by the whistleblower,

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