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1. Please select the option(s) that best describes your complaint.

A. Fraudulent representations that persuaded you to trade futures, options, swaps, forex, or leveraged transactions.

If a rate of return was promised to you, what was the rate of return?

Were you promised that the risk of loss trading futures was limited?

Were you told something about the experience of the person(s) trading your funds that you later found out was untrue?

If none of the above, describe what you were told that you now believe to be untrue.

Are there other potential victims that you know of? Please identify.

Did the conduct occur within the United States?

B. Some type of cheating or fraud that occurred after you had deposited funds to trade futures, options, swaps, forex, retail commodity, or leveraged transactions (for example, if someone used the funds you deposited to pay off someone else or you have asked for the return of your funds and have been refused).

To your knowledge, are there any funds remaining?

Do you know the name of the futures commission merchant that processed the trades?

Are there other potential victims that you know of?

Did the conduct occur within the United States?

C. Someone or some firm that should be registered under the Commodity Exchange Act, but is not.

Describe the conduct that you believe requires the person or firm to be registered under the CEA.

Did the conduct occur within the United States?

D. Disruptive or manipulative trading activity in the futures, options or swaps markets.

What is the source of your belief that someone or some entity has engaged in either a disruptive trading practice or manipulative activity?

On what days, and if you know, what time of day, did the alleged conduct occur?

On what exchange or market did the activity occur?

What prices, if any, were affected by the alleged conduct?

Did the conduct occur within the United States?

E. The trading of futures options, or swaps based upon confidential information by someone not allowed to use such information.

Was the confidential information held or created by the Federal Government?

Did the Federal Government generally disseminate the information prior to the alleged trading activity?

Did a Federal employee or agent use the information to trade a futures contract, an options contract, or a swap?

Did a Federal employee or agent provide the confidential information to someone else that this other person could trade a futures contract, an options contract, or a swap?

Did someone steal the confidential information and use it to trade a futures contract, an options contract or a swap?

Did the confidential information belong to a person or a firm?

Identify that person or firm with contact information.

Did the conduct occur within the United States?

F. Complaint does not fit into any of the above-described categories.

5. Has the individual or firm who engaged in the conduct acknowledged their fault?

6. Have you or anyone else taken any action against the firm or person who engaged in the alleged conduct?

A state or federal criminal law enforcement entity.

A legal action filed against the person or firm in a court of law.Additional comments based on above selection (e.g., Who, When, Contact, To whom made, Case Number, Court).7. Provide a brief description about what you are complaining about.SECTION 2. TELL US ABOUT THE INDIVIDUAL AND/OR FIRM YOU ARE COMPLAINING ABOUT

Important Instructions:Please provide the following information to the extent known for each individual or firm that is a subject of your complaint.To add additional individuals or firms, provide the information below for the first individual or firm, and then select theAdd Individual/Firmbutton at the end of Section 2.

Title that best describes what you are complaining about

Associated Person Of A Commodity Pool Operator

Associated Person of A Commodity Trading Advisor

Associated Person Of a Futures Commission Merchant

If you are complaining about a firm or individual that has custody or control of your investments, have you had difficulty contacting that entity or individual?

Are you or were you associated with the individual or firm when the alleged conduct occurred?

How are you or were you associated with the individual or firm you are complaining about?

What was the initial form of contact between you and the person against whom you are filing this complaint?

Important Instructions: You may provide information for multiple individuals or attorneys by pressing Add Submitter or Add Attorney after each entry.

Are you submitting this tip, complaint or referral anonymously? Being able to contact you for further information or clarification may be helpful.

Are you represented by an attorney in connection with your submission?

What is the best way to contact your attorney?

SECTION 4. TELL US ABOUT THE INSTRUMENTS INVOLVED IN YOUR COMPLAINT

Important Instructions: Please provide as much of the following information as possible relevant to your complaint. Select at least one or more of the options below that best describes the type of instrument involved.

Select the type of instrument involved in your complaint.

A futures contract, including a single stock futures contract, a narrow based or broad based security future contract.

An option on a futures contract, an option on a commodity, BUT NOT an option on a security or a basket of securities.

A swap, including a mixed swap BUT NOT a swap based on a single security or based on a narrow (i.e., nine or less) index of securities.

Are you an individual that trades or invests more than $10,000,000 on a discretionary basis?

Are you an individual that trades or invests more than $5,000,000 and enters into the foreign currency agreement to manage the risk associated with some other asset or liability?

A commodity transaction entered into or offered on a leveraged or margined basis, or financed by the offeror, the counterparty, or someone acting in concert with the offeror or counterparty.

Are you an individual that trades or invests more than $10,000,000 on a discretionary basis?

Are you an individual that trades or invests more than $5,000,000 and enters into the foreign currency agreement to manage the risk associated with some other asset or liability?

A cash (or physical) contract traded in interstate commerce?

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