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Contingent Trade Reporting Form

Contingent transaction type:

General information

Individual submitting report

Approved participant:

Name:

Title:

Email:

SAM authorized person executing the contingent transaction

Name:

SAM user ID:

Telephone:

Fax:

Details of the contingent transaction

* Transaction type:

Cross transaction Trade against another firm

Counterparty name:

Trade date and time: at :

Futures contract component

Symbol:

Contract month & year:

Quantity:

Transaction price:

Buyer / Seller:

Cash component or OTC derivative instrument of the contingent transaction

Description:

Quantity or value:

Market value:

Correlation: ?

Buyer / Seller:

Additional details:

Authorized person means a SAM Authorized Person or any other person authorized by a regulator or a self-regulatory organization to deal in futures contracts.

The transmission of the above information to the Bourse and the subsequent validation and dissemination of the transaction by the Market Monitoring Department will not preclude the Bourse from initiating any analysis and/or investigation to ensure that the transaction has been made in accordance with the requirements of the Rules of the Bourse or of the Procedures for the execution and reporting of exchange for physical (EFP), exchange for risk (EFR) and substitution of OTC derivative instruments for futures contracts transactions. If, following such analysis or investigation, it appears that the transaction was not in full compliance with applicable regulatory requirements, the Bourse has the discretion to initiate a disciplinary process.