Fillable Printable Form Wb-App
Fillable Printable Form Wb-App
Form Wb-App
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OMB Number 3235-0686
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SEC2851 (08-11)
UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
Washington, DC 20549
FORM WB-APP
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)
1. Last Name
First
M.I.
Social
Security No.
2. Street Address
Apartment/
Unit #
City
State/
Province
ZIP Code
Country
3. Telephone
Alt. Phone
E-mail Address
B. ATTORNEY’S INFORMATION (IF APPLICABLE – SEE INSTRUCTIONS)
1. Attorney’s Name
2. Firm Name
3. Street Address
City
State/
Province
ZIP Code
Country
4. Telephone
Fax
E-mail Address
C. TIP/COMPLAINT DETAILS
1. Manner in which original information was submitted to SEC: SEC website
Mail Fax Other ______________
2a. Tip, Complaint or Referral number
2b. Date TCR referred to in 2a submitted to SEC / /
2c. Subject(s) of the Tip, Complaint or Referral:
D. NOTICE OF COVERED ACTION
1. Date of Notice of Covered Action to which claim relates: / /
2. Notice Number:
3a. Case Name
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 / /
3b. Date action filed by agency/organization / /
4a. Case Name
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 ("SEC" or "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 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
laws by an independent public accountant? YES
NO
4. Did you provide the information identified in Section C above 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 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 “No” 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)
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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 other routine uses as
described in SEC-42 “Enforcement Files.”
Furnishing this information is voluntary, but a decision not do so, or failure to provide complete
information, may result in our denying a whistleblower award to you, or may affect our evaluation of the
appropriate amount of an award. Further, if you are submitting this information for the SEC whistleblower
program and you do not execute the Declaration, you may not be considered for an award.
Questions concerning this form may be directed to the SEC Office of the Whistleblower, 100 F Street, NE,
Washington, DC 20549-5631, Tel. (202) 551-4790, Fax (703) 813-9322.
General
• This form should be used by persons making a claim for a whistleblower award in connection with
information provided to the SEC or to another agency in a related action. In order to be deemed
eligible for an award, you must meet all the requirements set forth in Section 21F of the Securities
Exchange Act of 1934 and the rules thereunder.
• You must sign the Form WB-APP as the claimant. If you provided your information to the SEC
anonymously, you must now disclose your identity on this form and your identity must be verified
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in a form and manner that is acceptable to the Office of the Whistleblower prior to the payment of
any award.
o If you are filing your claim in connection with information that you provided to the SEC,
then your Form WB-APP, and any attachments thereto, must be received by the SEC
Office of the Whistleblower within ninety (90) days of the date of the Notice of
Covered Action to which the claim relates.
o If you are filing your claim in connection with information you provided to another agency
in a related action, then your Form WB-APP, and any attachments thereto, must be
received by the SEC Office of the Whistleblower as follows:
• If a final order imposing monetary sanctions has been entered in a related action
at the time you submit your claim for an award in connection with a Commission
action, you must submit your claim for an award in that related action on
the same Form WB-APP that you use for the Commission action.
• If a final order imposing monetary sanctions in a related action has not been
entered at the time you submit your claim for an award in connection with a
Commission action, you must submit your claim on Form WB-APP within
ninety (90) days of the issuance of a final order imposing sanctions in the
related action.
• You must submit your Form WB-APP to us in one of the following two ways:
o
o
By mailing or delivering the signed form to the SEC Office of the Whistleblower, 100 F Street
NE, Washington, DC 20549-5631; or
By faxing the signed form to (703
) 813-9322.
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Instructions for Completing Form WB-APP
Section A: Applicant’s Information
Questions 1-3: Provide the following information about yourself:
First and last name, and middle initial
•
Social Security Number
Complete address, including city, state and zip code
• Telephone number and, if available, an alternate number where you can be reached
• E-mail address
Section B: Attorney’s Information. If you are represented by an attorney in this matter, provide
the information requested. If you are not represented by an a
ttorney in this matter, leave this
Section blank.
Questions 1-4: Provide the following information about the attorney representing you in this matter:
•
•
•
•
•
Attorney’s name
Firm name
Complete address, including city, state and zip code
Telephone number and fax number, and
E-mail address.
Section C: Tip/Complaint Details
Que
stion 1: Indicate the manner in which your original information was submitted to the SEC.
Question 2a: Include the TCR (Tip, Complaint or Referral) number to which this claim relates.
Question 2b: Provide the date on which you submitted your information to the SEC.
Question 2c: Provide the name of the individual(s) or entity(s) to which your complaint related.
Section D: Notice of Covered Action
The process for making a claim for a whistleblower award begins with the publication of a “Notice
of Covered Action” on the Commission’s website. This Notice is published whenever a judicial
or administrative action brought by the Commission results in the imposition of monetary
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•
•
SEC2851 (08-11)
sanctions exceeding $1,000,000. The Notice is published on the Commission’s website
subsequent to the entry of a final judgment or order in the action that by itself, or collectively with
other judgments or orders previously entered in the action, exceeds the $1,000,000 threshold.
Question 1: Provide the date of the Notice of Covered Action to which this claim relates.
Question 2: Provide the notice number of the Notice of Covered Action.
Question 3a: Provide the case name referenced in Notice of Covered Action.
Question 3b: Provide the case number referenced in Notice of Covered Action.
Section E: Claims Pertaining to Related Actions
Question 1: Provide the name of the agency or organization to which you provided your information.
Question 2: Provide the name and contact information for your point of contact at the agency or
organization, if known.
Question 3a: Provide the date on which you provided your information to the agency or
organization referenced in question E1.
Question 3b: Provide the date on which the agency or organization referenced in question E1 filed the
related action that was based upon the information you provided.
Question 4a: Provide the case name of the related action.
Question 4b: Provide the case number of the related action.
Section F: Eligibility Requirements
Question 1: State whether you are currently, or were at the time you acquired the original information
that you submitted to the SEC, a member, officer, or employee of the Department of
Justice; the Securities and Exchange Commission; the Comptr
oller of the Currency, the
Board of Governor
s 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.
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SEC2851 (08-11)
Q
• Section 3(a)(52) of the Exchange Act (15 U.S.C. §78c(a)(52)) currently defines
‘‘foreign financial regulatory authority’’ as “any (A) foreign securities authority, (B)
other governmental body or forei
gn equivalent of a self-regulatory organization
empowered by a foreign government to administer or enforce its laws relating to
the regulation of fiduciaries, trusts, commercial lending, insurance, trading in
contracts of sale of a commodity for future delivery, or other instruments traded
on or subject to the rules of a contract market, board of trade, or foreign
equivalent, or other financial activities, or (C) membership organization a function
of which is to regulate participation of its members in activities listed above.”
Question 3: Indicate whether you acquired the information you provided to the SEC through the
performance of an engagement required under the Federal securities laws by an independent
public accountant.
Question 4: State whether you provided the information submitted to the SEC pursuant to a
cooperation agreement with the SEC or with any other agency or organization.
Question 5: State whether you are a spouse, parent, child or sibling of a member or employee of the
Commission, or whether you reside in the same household as a member or employee of
the Commission.
Question 6: State whether you acquired the information you are providing to the SEC from any
individual described in Question 1 through 5 of this Section.
Question 7: If you answered “yes” to questions 1 though 6, please provide details.
Question 8a: State whether you provided the information identified to the SEC before you (or
anyone representing you) received any request, inquiry or demand from the SEC,
uestion 2: State whether you are, or were you at the time you acquired the original information you
submitted to the SEC, 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.
SEC2851 (08-11)
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Congress, or any other federal, state or local authority, or any self regulatory
organization, or the Public Company Accounting Oversig
ht Board about a matter to which
the information in your submission was relevant.
Question 8b: If you answered “no” to questions 8a, please provide details. Use additional sheets if
necessary.
Question 9a: State whether you are the subject or target of a criminal investigation or have been
convicted of a criminal violation in connection with the information upon which your
application for award is based.
Question 9b: If you answered “yes” to question 9a, please provide details, including the name of the
agency or organization that conducted the investigation or initiated the action against
you, the name and telephone number of your point of contact at the agen
cy or
organization, if available and the investigation/case name and number, if applica
ble. Use
additional sheets, if necessary.
Section G: Entitlement to Award
This section is optional. Use this section to 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 connection with a related action. Specifically address how you believe you voluntarily provided
the Commission with original information that led to the successful enforcement of a judicial or
administrative action filed by the Commission, or a related action. Refer to Rules 21F-3 and 21F-
4 under the Exchange Act for further information concerning the relevant award criteria. You may
attach additional sheets, if necessary.
Rule 21F-6 under the Exchange Act provides that in determining the amount of an award, the
Commission will evaluate the following factors: (a) the significance of the information provided by
a whistleblower to the success of the Commission action or related action; (b) the degree of
assistance provided by the whistleblower and any legal representative of the whistleblower in the
SEC2851 (08-11)
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Commission action or related action; (c) the programmatic interest of the Commission in deterring
violations of the securities laws by making awards to whistleblowers who provide information that
leads to the successful enforcement of such laws; and (d) whether the award otherwise enhances
the Commission’s ability to enforce the federal securities laws, protect investors, and encourage
the submission of high-quality information from whistleblowers. Address these factors in your
response as well.
Additional information about the criteria the Commission may consider in determining the amount
of an award is available on the Commission’s website at www.sec.gov/whistleblower.
Section H: Declaration
This section must be signed by the claimant.
SEC2851 (08-11)
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