UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washington, D.C FORM WB-DEC

Transcription

1 UNITED STATES SECURITIES AND EXCHANGE COMMISSION Washingtn, D.C FORM WB-DEC DECLARATION OF ORIGINAL INFORMATION SUBMITTED PURSUANT TO SECTION 21F OF THE SECURITIES EXCHANGE ACT OF 1934 A. SUBMITTER S INFORMATION 1. Last Name First M.I. 2. Street Address Apartment/ Unit # City State/ Prvince ZIP Cde Cuntry 3. Telephne Alt. Phne Address B. ATTORNEY INFORMATION (If Applicable - See Instructins) 1. Attrney s name 2. Firm Name 3. Street Address City State/ Prvince ZIP Cde Cuntry 4. Telephne Fax Address C. TIP/COMPLAINT DETAILS 1. Manner in which infrmatin was submitted t SEC: SEC website Mail Fax Other 2a. Tip, Cmplaint r Referral (TCR) number: (Required if yu submitted yur infrmatin thrugh SEC website) 2b. Date TCR referenced in 2a submitted t SEC / / 2c. Individual r entity t which Tip, Cmplaint r Referral relates: 3a. Has the submitter r cunsel had any cmmunicatin(s) with the SEC cncerning this matter? YES NO 3b. If the answer t 3a is Yes, name f SEC staff member with whm the submitter r cunsel cmmunicated 4a. Has the submitter r cunsel prvided the infrmatin t any ther agency r rganizatin? YES NO 4b. If the answer t 4a is Yes, please prvide details. Use additinal sheets if necessary 4c. Name and cntact infrmatin fr pint f cntact at agency r rganizatin, if knwn D. ELIGIBILITY REQUIREMENTS 1. Are yu, r were yu at the time yu acquired the riginal infrmatin yu submitted t us, a member, fficer r emplyee f the Department f Justice, the Securities and Exchange Cmmissin, the Cmptrller f the Currency, the Bard f Gvernrs f the Federal Reserve System, the Federal Depsit Insurance Crpratin, the Office f Thrift Supervisin; the Public Cmpany Accunting Oversight Bard; any law enfrcement rganizatin; r any natinal securities exchange, registered securities assciatin, registered clearing agency, the Municipal Securities Rulemaking Bard? YES NO

2 2. Are yu, r were yu at the time yu acquired the riginal infrmatin yu submitted t us, a member, fficer r emplyee f a freign gvernment, any plitical subdivisin, department, agency, r instrumentality f a freign gvernment, r any ther freign financial regulatry authrity as that term is defined in Sectin 3(a)(52) f the Securities Exchange Act f 1934 (15 U.S.C. 78c(a)(52))? YES NO 3. Did yu btain the infrmatin yu are prviding t us thrugh the perfrmance f an engagement required under the federal securities laws by an independent public accuntant? YES NO 4. Did yu prvide the infrmatin identified in Sectin C abve pursuant t a cperatin agreement with the SEC r anther agency r rganizatin? YES NO 5. Are yu a spuse, parent, child, r sibling f a member r emplyee f the Cmmissin, r d yu reside in the same husehld as a member r emplyee f the Cmmissin? YES NO 6. Did yu acquire the infrmatin yu are prviding t us frm any persn described in questins D1 thrugh D5? YES NO 7. If yu answered yes t any f questins 1 thrugh 6 abve, please prvide details. Use additinal sheets if necessary. 8a. Did yu prvide the infrmatin identified in Sectin C abve befre yu (r anyne representing yu) received any request, inquiry r demand frm the SEC, Cngress, r any ther federal, state r lcal authrity, r any self regulatry rganizatin, r the Public Cmpany Accunting Oversight Bard abut a matter t which the infrmatin yur submissin was relevant? YES NO 8b. If yu answered n t questin 8a, please prvide details. Use additinal sheets if necessary. 9a. Are yu currently a subject r target f a criminal investigatin, r have yu been cnvicted f a criminal vilatin, in cnnectin with the infrmatin upn which yur applicatin fr an award is based? YES NO 9b. If yu answered Yes t questin 9a, please prvide details. Use additinal sheets if necessary. E. DECLARATION I declare under penalty f perjury under the laws f the United States that the infrmatin cntained herein, and all infrmatin submitted t the SEC either in the TCR referenced in Sectin C f this frm r in the Frm TCR accmpanying this Frm WB-DEC - is true, crrect and cmplete t the best f my knwledge, infrmatin and belief. I fully understand that I may be subject t prsecutin and ineligible fr a whistleblwer award if, in my submissin f infrmatin, my ther dealings with the SEC, r my dealings with anther authrity in cnnectin with a related actin, I knwingly and willfully make any false, fictitius, r fraudulent statements r representatins, r use any false writing r dcument knwing that the writing r dcument cntains any false, fictitius, r fraudulent statement r entry. Signature F. COUNSEL CERTIFICATION I certify that I have verified the identity f the whistleblwer wh cmpleted Frm WB-DEC in cnnectin with the infrmatin referenced in Sectin C f this frm by viewing the whistleblwer s valid, unexpired gvernment issued identificatin (e.g., driver s license, passprt), that I have reviewed the whistleblwer s Frm WB-DEC fr cmpleteness and accuracy, and that I will retain an riginal, signed cpy f the Frm WB-DEC cmpleted by the whistleblwer in my recrds. Date Signature Date

3 Privacy Act Statement This ntice is given under the Privacy Act f The Privacy Act requires that the Securities and Exchange Cmmissin (SEC) infrm individuals f the fllwing when asking fr infrmatin. The infrmatin prvided will enable the Cmmissin t determine yur eligibility fr payment f an award pursuant t Sectin 21F f the Securities Exchange Act f This infrmatin may be disclsed t Federal, state, lcal, r freign agencies respnsible fr investigating, prsecuting, enfrcing, r implementing the federal securities laws, rules, r regulatins cnsistent with the cnfidentiality requirements set frth in Sectin 21F(h)(2) f the Exchange Act and 21F-7 f this chapter. Furnishing the infrmatin is vluntary, but a decisin nt t d s may result in yu nt being eligible fr award cnsideratin. Questins cncerning this frm may be directed t the SEC Whistleblwer Office, 100 F Street, NE, Washingtn, D.C XXXX, Tel. (800) XXX-XXXX, Fax (202) XXX-XXXX. General Infrmatin Submitting infrmatin fr the SEC s whistleblwer award prgram is a tw-step prcess. First, yu must prvide us with yur infrmatin, which yu may d in either f tw ways. Yu may submit infrmatin electrnically thrugh the SEC s Electrnic Data Cllectin System available n the SEC web site at [insert link]. Utilizing the SEC s nline database is quick and easy and will enable yu t print and retain a date and time-stamped cnfirmatin f the infrmatin yu prvided t us. If yu prefer, yu may cmpete Frm TCR ( Tip, Cmplaint, r Referral ) manually, and mail r deliver it t us in hard cpy fllwing the instructins set frth n the frm. Submitting yur infrmatin t us is the first step. If yu want t be cnsidered fr a whistleblwer award, yu must als submit this Frm WB-DEC and it must be manually signed under penalty f perjury. If yu submitted yur infrmatin electrnically thrugh ur web site, we must receive yur cmpleted Frm WB-DEC within 30 days f yur submissin. If yu did nt submit yur infrmatin electrnically but instead are submitting yur infrmatin n Frm TCR,

4 yu must submit yur declaratin n Frm WB-DEC at the same time that yu submit yur Frm TCR. Fllw the instructins set frth belw fr submitting this Frm WB-DEC. If yu fllw these steps, and the infrmatin yu submit leads t the successful enfrcement f an SEC judicial r administrative actin, r a related actin, yu will have an pprtunity at a later date t submit a claim fr an award. That is a separate prcess and is described in ur whistleblwer rules, which are available at [insert link fr WBO website]. Yu have the right t submit infrmatin annymusly. If yu are ding s, please skip Part I f these instructins and prceed directly t Part II. Otherwise, please begin by fllwing the instructins in Part I. Part I: Instructins fr filers wh are disclsing their identity Yu are required t cmplete Sectins A, C, D, and E f this frm. If yu are represented by an attrney in this matter, yu must als cmplete Sectin B. Specific instructins fr answering these questins can be fund in Part IV belw. If yu previusly submitted yur cmplaint electrnically thrugh the SEC s web site, yu may submit this Frm WB-DEC t us in any f the fllwing ways: By mailing r delivering the signed frm t the SEC Whistleblwer Office, 100 F Street NE, Washingtn, D.C XXXX; r By faxing the signed frm t (202) XXX-XXXX; r By scanning and ing the frm in PDF frmat t [insert address]. Please nte that we must receive yur Frm WB-DEC within thirty (30) days f when yu submitted yur infrmatin t us thrugh ur web site. If yu did nt previusly submit yur cmplaint electrnically thrugh the SEC s web site, but instead intend t send us a Frm TCR, then yu must submit yur cmpleted Frm TCR and yur declaratin n this Frm WB-DEC tgether. Yu may d s in ne f tw ways:

5 By mailing r delivering the frm TCR and the signed frm WB-DEC t the SEC Whistleblwer Office, 100 F Street NE, Washingtn, D.C XXXX; r By faxing the frm TCR and the signed frm WB-DEC frm t (202) XXX-XXXX. Part II: Instructins fr annymus filers If yu are submitting infrmatin annymusly, yu must be represented by an attrney in this matter. If yu previusly submitted yur cmplaint annymusly thrugh the SEC s web site, make sure yur attrney knws this. If yu r yur attrney did nt previusly submit yur cmplaint electrnically thrugh the SEC s web site, but instead sent a Frm TCR t us, then cmplete yur Frm TCR and give it t yur attrney. Yu are als required t cmplete Sectins B, C, D, and E f this frm, and give the signed riginal t yur attrney. Specific instructins fr answering these questins can be fund in Part IV belw. In rder fr yu t be eligible fr a whistleblwer award, yur attrney must retain yur signed riginal f Frm WB-DEC in his r her recrds, and submit bth yur Frm TCR (if yu filled ne ut instead f submitting yur cmplaint t us electrnically) and an attrney declaratin t us. Yu are encuraged t cnfirm that yur attrney fllwed these steps. Part III: Instructins fr attrneys representing annymus whistleblwers Obtain a cmpleted and signed riginal f Frm WB-DEC frm yur client. Yu must retain this signed riginal in yur recrds because it may be required at a later date if yur client files a claim fr a whistleblwer award. Yu must prepare yur wn Frm WB-DEC, cmpleting nly Sectins B, C and F. Specific instructins fr answering these questins can be fund in Part IV belw. If yur client previusly submitted his r her cmplaint electrnically thrugh the SEC s web site, yu may submit yur attrney Frm WB-DEC t us in any f the fllwing ways: By mailing r delivering the signed frm t the SEC Whistleblwer Office, 100 F Street NE, Washingtn, D.C XXXX; r By faxing the signed frm t (202) XXX-XXXX; r

6 By scanning and ing the frm in PDF frmat t [insert address]. Please nte that we must receive yur Frm WB-DEC within thirty (30) days f when yur client submitted the infrmatin t us thrugh ur web site. If yur client did nt previusly submit his r her cmplaint electrnically thrugh the SEC s web site, but instead intends t submit a Frm TCR t us, then yu must submit yur client s cmplaint n Frm TCR and yur attrney declaratin n this Frm WB-DEC tgether. Yu may d s in ne f tw ways: By mailing r delivering the Frm TCR and the signed Frm WB-DEC t the SEC Whistleblwer Office, 100 F Street NE, Washingtn, D.C XXXX; r By faxing the Frm TCR and the signed Frm WB-DEC t (202) XXX-XXXX. Part IV: Instructins fr Cmpleting Frm WB-DEC: Sectin A: Submitter s Infrmatin Questins 1-3: Prvide the fllwing infrmatin abut yurself: First and last name, and middle initial Cmplete address, including city, state and zip cde Telephne number and, if available, an alternate number where yu can be reached address Sectin B: Infrmatin abut Yur Attrney. Cmplete this sectin nly if yu are represented by an attrney in this matter. Yu must be represented by an attrney, and this sectin must be cmpleted, if yu submitted yur infrmatin annymusly. Questins 1-4: Prvide the fllwing infrmatin abut the attrney representing yu in this matter: Attrney s name Firm name Cmplete address, including city, state and zip cde Telephne number and fax number, and

7 address Sectin C: Tip/Cmplaint Details Questin 1: Questin 2a: Indicate the manner in which the infrmatin was submitted t the SEC. Include the TCR (Tip, Cmplaint r Referral) number, if available. THE TCR NUMBER MUST BE INCLUDED ON FORM WB-DEC IN CASES WHERE THE ORIGINAL INFORMATION WAS SUBMITTED THROUGH THE SEC WEBSITE Questin 2b: Questin 2c: Questin 3a: Prvide the date n which the TCR referenced in 2a was submitted t the SEC. Prvide the name f the individual r entity t which yur cmplaint relates. Indicate whether the submitter r cunsel have had any cmmunicatin(s) with the SEC cncerning this manner. Questin 3b: If yu answered yes t questin 3a, prvide the name f the SEC staff member with whm the submitter r cunsel cmmunicated. Questin 4a: Indicate whether the submitted r cunsel have prvided the infrmatin being submitted t the SEC t any ther agency r rganizatin. Questin 4b: If yu answered yes t questin 4a, prvide details, including the name f the agency r rganizatin, the date n which yu prvided yur infrmatin t the agency r rganizatin and any ther relevant details. Questin 4c: Prvide a name and cntact infrmatin fr yur pint f cntact at the ther agency r rganizatin, if knwn. Sectin D: Eligibility Requirements Questin 1: State whether yu are currently, r were at the time yu acquired the riginal infrmatin that yu submitted t the SEC a member, fficer, r emplyee f the Department f Justice; the Securities and Exchange Cmmissin; the Cmptrller f the Currency, the Bard f Gvernrs f the Federal Reserve System, the Federal Depsit Insurance Crpratin, r the Office f Thrift Supervisin; the Public Cmpany Accunting

8 Oversight Bard; any law enfrcement rganizatin; r any natinal securities exchange, registered securities assciatin, registered clearing agency, the Municipal Securities Rulemaking Bard Questin 2: State whether yu are, r were yu at the time yu acquired the riginal infrmatin yu submitted t the SEC, a member, fficer r emplyee f a freign gvernment, any plitical subdivisin, department, agency, r instrumentality f a freign gvernment, r any ther freign financial regulatry authrity as that term is defined in Sectin 3(a)(52) f the Securities Exchange Act f Sectin 3(a)(52) f the Exchange Act (15 U.S.C. 78c(a)(52)) currently defines freign financial regulatry authrity as any (A) freign securities authrity, (B) ther gvernmental bdy r freign equivalent f a self-regulatry rganizatin empwered by a freign gvernment t administer r enfrce its laws relating t the regulatin f fiduciaries, trusts, cmmercial lending, insurance, trading in cntracts f sale f a cmmdity fr future delivery, r ther instruments traded n r subject t the rules f a cntract market, bard f trade, r freign equivalent, r ther financial activities, r (C) membership rganizatin a functin f which is t regulate participatin f its members in activities listed abve. Questin 3: Indicate whether yu acquired the infrmatin yu prvided t the SEC thrugh the perfrmance f an engagement required under the securities laws by an independent public accuntant. Questin 4: State whether yu prvided the infrmatin submitted t the SEC pursuant t a cperatin agreement with the SEC r with any ther agency r rganizatin. Questin 5: State whether yu are a spuse, parent, child r sibling f a member r emplyee f the Cmmissin, r whether yu reside in the same husehld as a member r emplyee f the Cmmissin. Questin 6: State whether yu acquired the infrmatin yu are prviding t the SEC frm any individual described in Questin 1 thrugh 5 f this Sectin

9 Questin 7: Questin 8a: If yu answered yes t questins 1 thugh 6, please prvide details. State whether yu prvided the infrmatin identified submitted t the SEC befre yu (r anyne representing yu) received any request, inquiry r demand frm the SEC, Cngress, r any ther federal, state r lcal authrity, r any self regulatry rganizatin, r the Public Cmpany Accunting Oversight Bard abut a matter t which the infrmatin yur submissin was relevant. Questin 8b: If yu answered n t questins 8a, please prvide details. Use additinal sheets if necessary. Questin 9a: State whether yu are the subject r target f a criminal investigatin r have been cnvicted f a criminal vilatin in cnnectin with the infrmatin upn which yur applicatin fr award is based. Questin 9b: If yu answered yes t questin 7a, please prvide details, including the name f the agency r rganizatin that cnducted the investigatin r initiated the actin against yu, the name and telephne number f yur pint f cntact at the agency r rganizatin, if available and the investigatin/case name and number, if applicable. Use additinal sheets, if necessary. Sectin E: Declaratin T be cmpleted and signed by persn submitting the infrmatin Sectin F: Cunsel Certificatin T be cmpleted and signed by attrney fr an annymus persn submitting infrmatin